HospitalInspections.org

Based on interview, medical record review, review of patient complaints and interventions, the facility failed to ensure that the patient received care in a safe environment for 1 of 1 patients (#2) who filed a grievance alleging staff bullying and disrespect . Findings include:

On 12/10/12 at approximately 2:30 pm during a review of patient complaints and interventions, it was noted that patient #2 had written a recipient rights complaint that was filed with the office of recipient rights on 10/25/11. Complaints # 1-25183913 & 1-25183932 state that patient #2 alleges that in September 2011 staff #10 "bullied him and made fun of him because he repeatedly brushed his teeth."

The investigation report indicates Staff #8 (rights officer) conducted an interview with patient #2 on 10/25/11 in which patient #2 repeats his allegation that he was bullied by staff #10 by him making fun of patient #2 for brushing his teeth often. Staff #8 then interviewed staff #10 (resident care assistant) on 12/14/11, almost 2 months after the complaint allegation was received by the office of recipient rights. The investigation report documents that staff #10 denied bullying or making any comments regarding patient #2's hygiene or how often he brushed his teeth.

Staff #8 then included in her investigation 11 questionnaires sent to staff #10 and ten other staff members regarding the allegations made by patient #2. The accused staff (staff #10) filled out a questionnaire in which he wrote "N/A" in response to a question asking him to describe any comments that he may have made to patient #2 regarding his hygiene. Staff #10 also crossed out the question, "In your opinion, have you treated recipient (patient #2) with dignity and respect?"

During an interview on 12/12/12 at approximately 10:30 am, Staff #8 was queried as to why Staff #10 was able to answer "N/A" on the questionnaire and to cross out a question without any further follow up questions. Staff #8 replied that she had crossed out the above mentioned question because she did not want Staff #10's "opinion" but rather the facts. Staff #8 stated she interviewed Staff #10 on 12/14/11 to supplement the questionnaire. The investigation file failed to include for review any documentation of the interview on 12/14/11.

Other staff questionnaires raise concerns as well. The summary report of the complaint states, the "questionnaire from (Staff #14)...did not witness RCA (Staff #10) make fun of or bully recipient (patient #2)." When in fact the questionnaire filled out by Staff #14 for the question, "In your opinion, has RCA (Staff #10) treated recipient (patient #2) with dignity and respect" is answered with "unable to determine on restrictions at time." Two additional staff questionnaires ask the same question, "In your opinion, has RCA (Staff #10) treated recipient (patient #2) with dignity and respect "and both Staff #11 and Staff #12 responded "No" to this question. Which indicates in their opinion that Staff #10 has not treated patient #2 with dignity and respect."

During an interview on 12/12/12 at approximately 10:30 am, Staff #8 was queried as to any further follow up questions for the 2 staff members that indicate that patient #2 was not treated with dignity and respect by Staff #10. Staff #8 stated that they (Staff #11 & 12) probably misread the question or didn't understand the question.

The facility failed to ensure the patient receives care in a safe environment which includes an emotionally safe environment consisting of respect and dignity.

Based on interview, medical record review, review of patient complaints and interventions, the facility failed to ensure that PRN (as needed) medications were administered as ordered for 1 of 3 patients (#2) reviewed with PRN pain or respiratory medications resulting in the potential for increased pain and respiratory distress. Findings include:

On 12/10/12 at approximately 2:00 pm during medical record review (patient #2), it was documented in the progress notes on 11/14/11 at 4:45 am "Pt (patient) complained about lower back pain..." A review of the patient's pain assessment flow sheet for scheduled & PRN pain medication indicates there was no documented pain assessments on 11/14/11. A review of the medication administration record indicates that on 11/11/11 the physician ordered ultram 50 mg by mouth every 4 hours PRN pain for one week. The medication administration record further indicates that no pain medication was administered on 11/14/11 as ordered by the physician for patient #2 who had complained of lower back pain.

On 12/10/12 at approximately 2:30 pm during a review of patient complaints and interventions, it was noted that patient #2 had filed a recipient rights complaint that was stamped "Received 11/14/11". Within the complaint patient #2 stated, "Thy [sic] are refusing my pain killer..." An intervention response dated 1/17/12 and signed by recipient rights officer staff #9 for allegation #1-25958057 states, "The following action has been taken: ORR has reviewed your complaint and found insufficient evidence to substantiate a rights violation." There is no indication in the complaints file as to what evidence Staff #9 reviewed in order to conclude that patient #2's rights had not been violated.

During further review of the medical record for patient #2, it was documented in the progress notes on 10/12/11 at 11:55 am, " Pt complained of having difficulty breathing. No dyspnea observed...Dr. (named) notified. Per MD: pt has albuterol inhaler and to give him his inhaler, then he will see pt. Will continue to monitor. No distress noted." A review of the medication administration record indicates that on 8/16/11 at 2:00 pm the physician had ordered albuterol sulfate HFA 90 mcg 2 puff inhalation every 4 hours as needed for wheezing and shortness of breathe. The medication administration record further indicates that no albuterol inhaler was administered on 10/12/11 as ordered by the physician for patient #2 who had complained of having difficulty breathing.

During an interview on 12/10/12 at approximately 2:45 pm, staff #9 was queried regarding the patient complaint (#1- 2598057) that he did not receive his pain medication. Staff #9 stated, that he went up and "talked with the patient" and that patient #2 didn't remember writing the complaint and couldn't give any specifics regarding the incident.

The facility failed to ensure that PRN medications were administered as ordered.