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Based on medical record review, policy and procedure review and staff interview the facility failed to document and investigate a complaint filed on behalf of one (Patient # 4) of six patients reviewed.

Findings include:

The medical record review for Patient #4 was completed on 5/04/16. Patient #4 was admitted to the hospital's Senior Behavioral Health (SBH) unit on 3/15/16 with diagnoses that included Alzheimer's, Dementia and combative.

Nursing documentation on 4/11/16 revealed a note at 2:26 AM that included "some discoloration noted on right side of face, no swelling, no pain noted".

The "15 Minute Safety Checks" documentation in the nurses notes revealed the patient was up walking in the hallway from 2:00 AM until 5:30 AM. A nurse's note on 4/11/16 at 8:49 AM revealed, "around right eye bruised".

A social worker note on 4/11/16 at 10:05 AM revealed, "Patient awoke with a bruise on her eye. There has not been a fall documented nor an altercation, medicine team to assess. Patient is to discharge today, back to her facility at 12:30 PM."

A physician progress note dated 4/11/16 revealed, "nursing reports new right eye ecchymosis overnight; no observed injury/fall."

Review of the facility's policy titled, "Client Rights Policy and Grievance Procedure" for the SBH department, item "D", bullet point #3 reads, "When a concern is communicated to any staff person, that staff person will immediately investigate or ask his/her supervisor to do so."

Review of the facility's policy titled, "Sentinel Events/Adverse Events", item "C", bullet point #1 reads, "Any employee, resident, student, physician, administrator or persons performing work for UTMC who is aware of an incident that may be an Adverse Event or Sentinel Event is responsible for contacting the House Supervisor and for entering an Incident Report into the Patient Safety Net in accordance with the Patient Safety Event Reporting Policy...."

Interview with Staff A and B on 5/04/16 at 11:30 AM revealed the nurse who noted the discoloration at 2:26 AM on 4/11/16 did not enter it into the "Patient Safety Net" computerized reporting system. Interview also revealed the hospital social worker had received a phone call from the SP's daughter after the patient was discharged inquiring about the patient's eye bruising. Staff A and B reported the social worker never logged the verbal complaint into the SBH complaint log as is required by policy. During the interview Staff A and B confirmed the patient's bruised eye was never investigated as hospital policy and procedure instructs.

Based on record review, staff interview, and review of patient rights, the facility failed to ensure that the patients' representative was informed of the patients' current health care status, ie. a fall, in order to make informed decisions regarding care. This affected two (Patient #4, #6) of six medical records reviewed.

Findings include:

1) Review of the medical record for patient #6 revealed the Patient was admitted to the SBH (Senior Behavioral Health) unit on 3/10/16 with diagnoses that include: MRDD (mentally retarded/developmentally delayed), bipolar disorder, and increased agitation. The medical record listed two emergency contacts for the patient. On 03/22/16 at 11:35 AM, Patient #6 sustained a fall in the dining room. The medical record did not contain evidence that either of the emergency contacts were notified of the fall.

On 05/04/16 at 11:10 AM an interview was conducted with Staff B who confirmed the patient's representatives were not notified of the fall.

Review of the Patient's Rights for the Senior Behavioral Health unit that is provided to all patients and his/her legal representative documents that: "You have the right to current information concerning your condition, treatment and progress" and "The patient and/or legally appointed representative are informed about unanticipated events that relate to sentinel events considered reviewable by The Joint Commission".

2) The medical record review for Patient # 4 was completed on 5/04/16. Patient # 4 was admitted to the hospital Senior Behavioral Health (SBH) unit on 3/15/16. Admitting diagnoses included Alzheimer's, Dementia and combative. Review of the medical record revealed the patient fell on 3/30/16 at 10:25 AM. Nursing documentation revealed "patient fell on left side, physician and director (of SBH) notified". The medical record did not contain documentation that the patient's emergency contact was notified of the fall.

Further review of the medical record revealed two separate falls on 4/08/16. Nursing documentation on 4/08/16 at 5:30 AM revealed, "Patient let go of her walker and intentionally fell backward. She was lowered to the floor by the nurse aide." On 4/08/16 at 6:38 AM nursing documentation revealed, "Patient intentionally fell backwards to the floor. Patient assessed and no signs of any distress, able to move all extremities with no apparent issue." On 4/08/16 at 7:03 AM nursing documentation revealed, "Dr. notified of patient fall."
The medical record did not contain documentation that the patient's emergency contact was notified of the falls.

Interview with Staff A and B on 5/03/16 at 2:20 PM confirmed the medical record did not contain documentation that the patient's emergency contact was notified of the patient's falls. During the interview, Staff B reported there is no hospital policy directing the staff to notify the patient's emergency contact or POA when a patient falls.

Of the six medical records reviewed during the survey, all of which were patient's from the SBH unit who had sustained a fall, four of the records contained documentation the patient's emergency contact/family/POA were notified of the fall.




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