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Based on record review and interview the facility failed to insure the rights of the patient/patient's representative upon discharge from the facility as evidenced by 1 of 1 patient discharged.


On 5/17/2011 at 9:30 Am in the administrative office the patient record was reviewed and the record revealed *Activity date: 4/30 2011 Time: 0928 Discharge instructions home health to continue. Accompanied at discharge: Family. Mode of discharge: Wheelchair. Destination Home*
Further review of the patient's medical record revealed the Patient was admitted from an Assisted living facility with a diagnosis of Alzhimer's Dementia. The patient's admission documentation was signed by the patient's Power of Attorney (POA) for medical decisions.

On 5/17/2011 at 9:45 AM in the administrative office the Patient's POA was contacted by phone. The POA was asked if she had been notified by hospital staff of the physician's decision to discharge. The POA stated "No". The POA was asked is she had been present for the discharge. The POA stated "No". The POA was asked if any other family member might have been present at the time of discharge to transport the patient from the facility. The POA stated "No". The POA went on to say the Assisted Living facility contacted her to tell her of the discharge.


Upon discharge there was no documentation the POA was notified of the physician's order to discharge nor was there any documentation the POA had been involved in the discharge process.
The patient was not discharged home as documented in the patient's medical record but was discharged to the Assisted living facility she had been admitted from.

Based on record review and interview the facility failed to act on grievance resolution within it's policy parameters based on 1 of 1 grievance reviewed.

On 5/17/2011 at 9:30 AM in the administrative office the complaint/grievance tracking log was reviewed it reviewed the patient's grievance was log in as received 5/2/2011.

On 5/17/2011 at 9:20 AM in the administrative office the facility policy SECTION 6.5 PATIENT COMPLAINT/GRIEVANCES was reviewed. Under section l POLICY B. The facility will respond in writing to all grievances within seven (7) working days. Under section lll PROCEDURE 3. b. The target for completion of investigation of all other grievances shall be seven (7) working days of receipt of the grievance. 4. An acknowledgement of the receipt of the filing will be provided to the patient and /or their legal representative within two (2) working days.

On 5/17/2011 at 9:30 AM in the administrative office the Director of Quality Management was asked if the grievance logged in for 5/2/2011 had been resoled. She answered no she was still investigating it. The Director was asked if a letter had been sent to the complainant at 7 days? The Director answered I don't know. When asked if a letter had been sent to acknowledge the receipt of the grievance and the answer was I don't think so.

Based on record review and interview the facility failed to provide patient care in a safe setting based on 1 of 1 patient records reviewed.


On 5/17/2011 at 10:00 AM in the administration office the patient's medical record was reviewed. The patient's medical record revealed an incomplete Admission Medication Reconciliation form. The medication reconciliation form list the following medications: ASA, Brovana, Exelon, Flovent, Lasix, Megestrol, Metoprolol, Mucinex, (Page 1). Nexium, Plavix, Sertraline, Simvastatin, Singulair, Spiriva, Synthroid, Ventolin, Zolpidem. (page 2). There was no documentation of strength, frequency or route. There was no documentation of last dose given or if any medication was to be continued in the hospital. There was no documentation of verification of the medication list from the Assisted Living facility the patient had been admitted from. There was documentation of a stated weight of 51.82 kg and allergies were listed as ASA, PCN. (Note the first medication listed as taken by the patient is ASA)

Further review of the patient's medical record revealed the following documentation: *Emergency Department Administration Record: Ativan 1 mg ordered at 1940 hours and administered at 1945 to the Left glut* further documentation reveals this order was repeated at 2022 hours. There was no documentation on the Emergency Department Ongoing Nursing Assessment notes as to why the injection was required to be given. There was no assessment documented on the Emergency Department Medication Administration Record of the patient's condition as improved, worsened, or unchanged from the firsts injection. There was no documentation why the second injection was required. There was no assessment documented on the Emergency Department Medication Administration Record after the second injection of the patient's condition improved, worsened or unchanged.

Further review of the patient's medical record revealed the Emergency Department Fall/Entrapment risk Assessment was not completed. The only documentation on the assessment, which was written in the score column, was *fall protection in place*. There was no documentation for Age, Mental Status, Elimination, Impairments, BP, Gait/Mobility, Current Medication, Predisposition Conditions.

Further review of the patient's inpatient records reveals on 4/26/2011 at 1930 hours Physicians orders included *No NSAIDS, ASA or IM injections* the Physicians Orders also included *Home meds as ordered on medication sheet*. The Patient's home medication sheet included ASA. On 4/27/2011 at 0900 hours ASA 81 mg was administered by the nurse on duty. On 4/28/2011 ASA 81 mg was administered by the nurse on duty. An order for Geodon 20 mg IM is documented as received at 2120 hours and administered 1 time only for agitation 4/26/11 at 2125 by the nurse on duty. There is no follow up documentation.

Further review of the patient's inpatient medical record reveals the admission nurses assessment documented Activity Date 4/26/11 Time: 2140 Alzheimer's Disease: N (N=No) (admission diagnosis Alzheimer's dementia), COPD: N (admission diagnosis COPD). The shift assessment dated 4/27/2011 (No time documented) recorded Braden score of 13 along with the statement : Score is 18 or less: N

On 5/17/2011 at 11:30 PM in the administration office the Assistant Director of Nurses confirmed the Emergency Department Admission forms were incomplete and Emergency Department nurse had documented very little.

Based on document review and interview the facility failed to provide patient needs based on accurate assessments as evidenced by 1 of 1 patient medical record reviewed.

On 5/17/2011 at 10:00 AM in the administration office the patient's medical record was reviewed. The patient's medical record revealed an incomplete Admission Medication Reconciliation form. The medication reconciliation form listed the following medications: ASA, Brovana, Exelon, Flovent, Lasix, Megestrol, Metoprolol, Mucinex, (Page 1). Nexium, Plavix, Sertraline, Simvastatin, Singulair, Spiriva, Synthroid, Ventolin, Zolpidem. (page 2). There was no documentation of strength, frequency or route. There was no documentation of last dose given or if any medication was to be continued in the hospital. There was no documentation of verification of the medication list from the Assisted Living facility the patient had been admitted from. There was documentation of a stated weight of 51.82 kg and allergies were listed as ASA, PCN. (Note the first medication listed as taken by the patient is ASA)

Further review of the patient's medical record revealed the following documentation: *Emergency Department Administration Record: Ativan 1 mg ordered at 1940 hours and administered at 1945 to the Left glut* further documentation reveals this order was repeated at 2022 hours. There was no documentation on the Emergency Department Ongoing Nursing Assessment notes as to why the injection was required to be given. There was no assessment documented on the Emergency Department Medication Administration Record of the patient's condition as improved, worsened, or unchanged from the firsts injection. There was no documented assessment why the second injection was required. There was no assessment documented on the Emergency Department Medication Administration Record after the second injection of the patient's condition improved, worsened or unchanged.

Further review of the patient's medical record revealed the Emergency Department Fall/Entrapment risk Assessment was not completed. The only documentation on the assessment, which was written in the score column, was *fall protection in place*. There was no assessment of documented criteria for Age, Mental Status, Elimination, Impairments, BP, Gait/Mobility, Current Medication, Predisposition Conditions.

Further review of the patient's inpatient records reveals on 4/26/2011 at 1930 hours Physicians orders included *No NSAIDS, ASA or IM injections* the Physicians Orders also included *Home meds as ordered on medication sheet*. The Patient's home medication sheet included ASA. On 4/27/2011 at 0900 hours ASA 81 mg was administered by the nurse on duty. On 4/28/2011 ASA 81 mg was administered by the nurse on duty. An order for Geodon 20 mg IM is documented as received at 2120 hours and administered 1 time only for agitation 4/26/11 at 2125 by the nurse on duty. There is no assessment documented regarding the conflict in medication orders and no clarification.

Further review of the patient's inpatient medical record reveals the admission nurses assessment documented Activity Date 4/26/11 Time: 2140 Alzheimer's Disease: N (N=No) (admission diagnosis Alzheimer's dementia), COPD: N (admission diagnosis COPD). The shift assessment dated 4/27/2011 (No time documented) recorded Braden score of 13 along with the statement : Score is 18 or less: N

On 5/17/2011 at 11:30 PM in the administration office the Assistant Director of Nurses confirmed the Emergency Department Admission forms were incomplete and Emergency Department nurse had documented very little.

On 5/17/2011 at 11:30 AM in the administrative office an overall review of documentation in the patient's medical record reveals incomplete, inaccurate and contradictory nursing documentation.

Based on record review and interview the facility failed to provide appropraite discharge planning based on 1 of 1 patient's discharge.

On 5/17/2011 in the administration office at 9:30 AM the patient record was reviewed and the record revealed *Activity date: 4/30 2011 Time: 0928 Discharge instructions home health to continue. Accompanied at discharge: Family. Mode of discharge: Wheelchair. Destination Home*
Further review of the patient's medical record revealed the Patient was admitted from an Assisted living facility with a diagnosis of Alzheimer's Dementia. The patient's admission documentation was signed by the patient's Power of Attorney (POA) for medical decisions.

On 5/17/2011 at 9:45 AM in the administrative office the Patient's POA was contacted by phone. The POA was asked if she had been notified by hospital staff of the physician's decision to discharge. The POA stated "No". The POA was asked is she had been present for the discharge. The POA stated "No". The POA was asked if any other family member might have been present at the time of discharge to transport the patient from the facility. The POA stated "No". The POA went on to say the Assisted Living facility contacted her to tell her of the discharge.

Upon discharge there was no documentation the POA was notified of the physician's order to discharge nor was there any documentation the POA had been involved in the discharge process.
The patient was not discharged home as documented in the patient's medical record but was discharged to the Assisted living facility she had been admitted from.

Further conversation with the POA revealed they had been notified by the Assisted Living that the hospital had faxed the new medication orders to their pharmacy and they would need to pick them up. Upon arrival at the pharmacy the POA was told the coumadin order could not be filled because the order received from the hospital was lacking the quantity of coumadin to be dispensed.

On 5/17/2011 at 1:15 PM in the patient's pharmacy the pharmacist confirmed the coumadin order could not be filled because the order was incomplete. He confirmed that no one was able to provide help to complete the order when the hospital Emergency Department had been contacted.

On 5/17/2011 at 1:15 PM while in the patient's pharmacy a copy of the order received from the hospital was reviewed and found to lack the quantity of coumadin to be dispensed.