HospitalInspections.org

Based on document review and interview the facility failed to protect the patient's rights by:
- not allowing the patients'/Durable Power of Attorney (DPOA) to participate in the master treatment plan for 2 of 2 patients (#24, #25) (A115)
- failed to inform the patients'/DPOA of a change in health status in 2 of 2 patients (#24, #25) (A131)
resulting in the patients'/DPOAs not being able to make informed decision about care and advocate for the patients resulting in a decline in condition.

Based on document review and interview, the facility failed to allow the Durable Power of Attorney (DPOA) to participate in the master treatment plan for 2 of 2 patients (#24, #25) resulting in the DPOAs not being able to advocate for the patients resulting in a decline in condition. Findings include:

On 11/14/14 at approximately 0815 during review of the undated policy titled, "Interdisciplinary Treatment Team Plan/Conference" section 2.21, states under #8. "The registered nurse will review and provide a copy of the treatment plan to the patient/family/guardian and document the following within 72 hours for inpatient treatment."

On 11/13/14 at approximately 1000 during medical record review for patient #25 it was revealed that the patient was not able to make decisions for himself due to dementia. The DPOA was not involved in the development of the master treatment plan.

On 11/13/14 at approximately 1330 it was confirmed with staff K that the patient and the DPOA were not involved with the master treatment plan.

On 11/14/14 at approximately 1115 during medical record review for patient #24 it was revealed that the patient was not able to make decisions for himself due to dementia. The DPOA was not involved in the development of the master treatment plan.

On 11/14/14 at approximately 1140 during an interview with staff GG it was confirmed that patient #24 and his DPOA was not involved in the master treatment plan.

Based on document review and interview the facility failed to inform the DPOA of the change in health status in 2 of 2 patients (#24, #25) resulting in the DPOAs not being able to make an informed decision about care and advocate for the patients resulting in a decline in condition and failed to give 1 of 1 patients (#20) the right to refuse treatment resulting in the potential for patients to be coerced into taking medications or receiving treatment that they do not agree to. Findings include:

On 11/14/14 at approximately 1115 during medical record review for patient #24 it was revealed that on 10/6/14 and 10/8/14 patient #24 fell and the DPOA was not notified.

On 11/14/14 at approximately 1140 during an interview with staff GG it was confirmed that patient #24's DPOA was not notified of either of the two falls.

On 11/13/14 at approximately 1130 during medical record review for patient #25 it was revealed that on 8/1/14, 8/2/14, 8/5/14, 8/7/14, 8/9/14 and 8/15/14 patient #25 fell and the DPOA was not notified.

On 8/18/14 staff documented in the progress notes that the patient "was not himself ", that he was "quiet" and did not "eat much" the DPOA was not notified of the changes. Prior to this fall, the patient was documented to be "hyper-verbal" and ate most of his meals. On 8/19/14 staff documented again that the patient "was not himself."

On 11/12/14 at approximately 1120 during a tour of the crisis unit this surveyor observed a medication pass for patient #20. Staff U told the patient that she was giving him Haldol and needed him to sign the consent for it. Patient #20 stated " I don't like how that one makes me feel, I don't want to take it. " Staff U stated " If you don't take it, then I will call the doctor and we will have you go to court. It will take about 7 to 8 days before you will be able to go. Then they will order you to take it and you will have to be here at least another 2 days taking the medication. So I need you to sign for this. " Patient #20 stated, " But, it makes me feel funny. " Staff U stated " Did the doctor talk to you about this med? " Patient #20 stated " No. " Staff U stated, " Yes he did, I heard him. So are you going to sign this and take it or not? " Patient #20 stated, " I don't remember him talking about it. " At this time staff K interrupted staff U and explained to patient #20 that he did not have to take the medication and that he could talk to his doctor about other medication options. Patient #20 did not take the medication.
On 11/12/14 at approximately 1125 during an interview with staff U and staff K this surveyor asked staff U, " Is he here voluntarily? " Staff U stated, " Yes " This surveyor then asked, " Is this how you typically pass your medications? " Staff U said, " Yes, I have to tell them they will go to court if they don't take what we are giving them. " This surveyor said, " It sounded like the patient did not have a right to refuse that medication, and he seemed very timid and almost scared to tell you he did not want the medication. When are the patients educated about the medications they are receiving and what their options are? " Staff U stated, " His doctor talked to him about it, I heard him. And, I educated him. That ' s what I was doing. " Staff K then stated to staff U, " We really need to tell the patients that they can talk to their doctors about other options for medications and give them an option. "

Based on document review and interview, the facility failed to ensure a thorough neglect investigation for 1 of 1 internal investigations reviewed for patient #25, resulting in a failure to identify system wide problems related to implementation of post-fall monitoring and a risk for harm for all patients who fall. Findings Include:

During review of the RCA (root cause analysis), that was performed on 9/2/14 it was revealed that the only action taken related to the incident was a new Fall Reduction Plan, which more clearly identified fall risk patients. The patient who fell multiple times, patient #25, was identified as high risk for fall starting on the day of admission. When the facility reviewed the case, they identified four falls, patient # 25's medical record, however six falls were reported. No post-fall interventions were identified. No "Action Items" to reduce risk were identified; these sections of the RCA tool were left blank. The "Plan of Action" column was also left blank. The facility's RCA did not show evidence of a thorough investigation, as evidenced by lack of details, and the incomplete and blank areas on the RCA tool and the lack of corrective action.

On 11/14/14 at approximately 0930 an interview took place with the following staff regarding the RCA for patient #25, which included the Medical Director, the CEO (chief executive officer), both physicians that cared for the patient, the manager of the Generations unit, where the patient #25 was hospitalized, the quality director, the CNO (chief nursing officer), the COO (chief operating officer), the social worker caring for the patient, this surveyor and the federal surveyor. This surveyor asked the group why sections of the RCA tool were left blank and what actions were taken to ensure patients who fell in the future, would be provided post-fall monitoring. An answer was not given related to the tool lacking details of action items. This surveyor then asked if any areas of concern were identified regarding patient monitoring after falls. Staff O stated, "We looked at the process leading up to the falls and changed our Fall Reduction Policy, but we did not look at the "back end" of the process (for patient monitoring) after the falls.

Based on document review and interview the facility failed to provide organized nursing services to monitor and respond to 2 of 2 patients' (#24, #25) needs after falls through assessment and documentation (A395) resulting in unmet care needs for the two patients and a decline in condition.

Based on document review and interview the facility failed to monitor 2 of 2 patients (#24, #25) after falls, resulting in injury and decline in condition. Findings include:

On 11/13/14 at approximately 1030, during medical record review the following was revealed:

The patient (#25) was a 91 year old male with a history of hypertension, dementia, glaucoma, falls, encephalopathy and skin cancer. He was on Asprin daily, prior to hospitalization then placed on subcutaneous heparin daily while at the hospital. The patient was admitted to the facility on 7/31/14.

On admission orders written on 7/31/14 fall precautions were ordered.

Fall #1 occurred on 8/1/14, no vital signs at the time of the fall were documented. The physician was notified and fall precautions were ordered again. No monitoring of the patient was documented after the first fall.

Fall #2 occurred on 8/2/14 with the 'lap buddy' noted to be beside the patient on the floor; the patient hit his head and had a small laceration on his head. The physician was notified, neurochecks were ordered for 24 hours, neurochecks and vital signs were routinely taken and documented for 22 hours. Vital signs were within normal limits (WNL).

Fall #3 occurred on 8/5/14. No evidence of vital signs, neurochecks or monitoring being done after the fall could be found in the medical record. The physician was notified, no new orders were given.

Fall #4 occurred on 8/7/14. No evidence of vital signs, neurochecks or monitoring being done after the fall could be found in the medical record. Vital signs were not taken at all on 8/7/14. The physician was notified, no new orders were given.

Fall #5 occurred on 8/9/14. No evidence of vital signs, neurochecks or monitoring being done, after the fall could be found in the medical record. The physician was notified, no new orders were given.

Fall #6 occurred on 8/15/14. No evidence of vital signs, neurochecks or monitoring being done after the fall could be found in the medical record. Vital signs were not taken at all on 8/16/14. The physician was notified, no new orders were given.

After all six of the falls, the treatment plan was not updated.

The patient was transferred out of the facility on 8/20/14 for a possible Gastrointestinal Bleed and a Hemoglobin level of 8.4. The patient died approximately 18 hours after being transferred to facility B. The death report from the Medical Examiner's (ME) office indicated the cause of death was "Blunt Traumatic Injuries of the Trunk," "Manner of Death: Accident"

On 11/13/14 at approximately 1400, during an interview with staff K the above findings regarding lack of nursing monitoring after the five falls for patient #25 were confirmed.

On 11/13/14 at approximately 1545, during an interview with staff E regarding patient #25 it was stated, "We probably should have transferred him sooner."

On 11/14/14 at approximately 1100, during review of the medical record for patient #24 the following was revealed:

The patient was a 85 year old male admitted on 10/2/14 with a history of dementia, degenerative joint disease, hypotension and arthritis.

On 10/6/14 the patient fell. No evidence of vital signs, neurochecks or monitoring being done after the fall could be found in the medical record. The physician was notified, no new orders were given.

On 10/8/14 the patient fell again. No evidence of vital signs, neurochecks or monitoring being done after the fall could be found in the medical record. The physician was notified, no new orders were given.

No evidence of vital signs could be found in the medical record for the days of 10/3/14, 10/8/14 and 10/9/14. The patient was transferred from the facility to facility B on 10/9/14 with a diagnosis of dehydration and a 19 pound weight loss.

On 11/14/14 at approximately 1140, during an interview with staff GG the above findings for patient #24 regarding lack of nursing monitoring after the falls were confirmed.