HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure two (#1 and #4) of nine (#1, #3-10) Medicare patients admitted to the Senior Care Unit signed initial Medicare Important Notices. Failure to ensure Medicare patients were issued the Medicare Important Notice within 48 hours of admission did not allow the patients the opportunity to be informed of and aware of their rights as a hospital patient. The failed practice had the likelihood to affect Patient #1 and #4. Findings follow:

A. Review of Patient #1's clinical record showed it did not contain a Medicare Important Notice signed within 48 hours of admission on 09/17/18. The Rehabilitation Unit Director verified the above findings during an interview at 1:10 PM on 06/27/19.

B. Review of Patient #4's clinical record showed it did not contain a Medicare Important Notice signed with 48 hours of admission on 09/26/18. The Rehabilitation Unit Director verified the above findings during an interview at 1:10 PM on 06/27/19.

Based on clinical record review, and interviews, it was determined a registered nurse failed to supervise and evaluate the nursing care in that five of five (#1, #3, #5, #8, and #9) clinical records did not contain evidence that patient care was rendered as directed by physician's orders. Review of the clinical records showed no evidence weights were obtained and documented three times per week and no evidence nutritional supplements were given. Failure to ensure weights were obtained and documented, and failure to ensure supplements were given, and the amounts consumed documented, did not give the treating physician access to information necessary to make informed decisions regarding the patient's care and treatment. The failed practice had the likelihood of affecting Patients #1, #3, #5, #8, and #9. Findings follow:

A. Review of Patient #1's clinical record showed an admission date of 09/17/18 and a discharge date of 09/24/18. Review of the physician's order dated 09/17/8 at 1729 showed orders for weights three times a week. Review of the clinical record showed two weights documented for the week (138 pounds on 09/17/18 and 138 pounds on 09/18/19). During an interview at 10:00 AM on 06/28/19 the Rehabilitation Unit Director verified the findings.

B. Review of Patient #3's clinical record showed an admission date of 12/30/18 and a discharge date of 01/22/19. Review of the physician's order dated 12/30/18 at 1734 showed orders for weights three times a week. Review of the clinical record showed only one weight (01/08/19 - 205 pounds) documented the second week (01/06/19), and no weights documented the third (01/13/19) week, and no weights documented the fourth week (01/20/19). During an interview at 10:00 AM on 06/28/19 the Rehabilitation Unit Director verified the findings.

C. The Chief Nursing Officer stated during an interview at 2:17 PM on 06/26/19, that all Senior Care patients were weighed every Sunday.

D. The Licensed Medical Social Worker stated during an interview at 10:40 AM on 06/27/19, that all Senior Care patients were weighed every Sunday.

E. The Rehabilitation Unit Director stated during an interview at 11:20 AM on 06/27/19, that all Senior Care patients were weighed every Sunday.

F. Review of Patient #5's clinical record showed orders dated 06/17/19 for Ensure at breakfast. Review of the clinical record showed no evidence the Ensure was given. During an interview with the Rehabilitation Unit Director at 1:50 PM on 06/27/19 the above findings were verified.

G. Review of Patient #8's clinical record showed orders dated 06/15/19 for Ensure with all meals. Review of the clinical record showed no evidence the Ensure was given. During an interview with the Rehabilitation Unit Director at 10:00 AM on 06/18/19 the above findings were verified.

H. Review of Patient #9's clinical record showed orders dated 06/17/19 for Boost with all meals. Review of the clinical record showed no evidence the Boost was given. During an interview with the Rehabilitation Unit Director at 10:35 AM on 06/28/19 the above findings were verified.