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MERIT HEALTH RANKIN 350 CROSSGATES BLVD BRANDON, MS 39042 Oct. 16, 2015
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on medical record review, policy and procedure review, and staff interview, the facility failed to follow the Vulnerable Persons Act Section 43-47-7, Mississippi Code of 1972 which required the facility to provide a written report of a complaint of abuse to the Mississippi State Department of Health within 72 hours for Patient #1, one (1) of nine (9) patients reviewed.


Findings include:


The facility failed to report the complaint of alleged physical abuse in writing to the Department of Health within 72 hours of discovery for Patient #1. An interview with the Patient Manager on 10/15/15 at 12:15 p.m. revealed that a written report of the incident was not sent to the State Department of Health/Licensure and Certification in writing because she did not know that it was required.


Record review for Patient #1 revealed the patient was a [AGE]-year-old male who was admitted to the facility's Senior Care Unit from a local nursing home on 9/15/15.

Review of Nurses' Note revealed:
9/16/15 -
At 4:30 p.m. the patient was very confused and delusional. He thought his kids called him and he's got somewhere to go. The patient has a poor appetite and only eats snacks and sweets. He paces the hallways and refused afternoon vital signs after several attempts. Fall precautions were followed per protocol.
At 9:10 p.m. the patient kept pacing the unit. He went into the nurse's station and kitchen area and would not leave. He kept saying this is my house...unable to redirect him.
At 9:38 p.m. the patient was given Ativan 0.5 milligrams (mg) orally. The patient continued to pace and come back into the nurses' station The RN (Registered Nurse) got a MHT (Mental Health Technician) to assist the patient because the patient listened better to a male voice. The MHT sat with the patient in his room for approximately 30 minutes. The patient was not calming down. The physician was called and an order was given to start the patient on Haldol 5 mg orally or IM (intramuscularly) twice a day. Haldol 5 mg was given IM in the left arm. The MHT continued sitting with the patient for approximately one (1) hour. The patient was sitting up on the side of his bed fidgeting. The RN then sat with the patient for approximately 30 minutes more. The patient was extremely disorganized, trying on clothes. He refused a sandwich or any foods.
9/17/15 -
At 6:10 a.m. the patient was hitting, kicking, punching staff and resistant to care. Feces was all over the patient. Two (2) MHT cleaned and dressed the patient.
At 2:00 p.m. the patient was oriented only to himself. He was very confused, disoriented, and very difficult to direct. It was noted early this a.m. that the patient's sclera was red in the left eye. His bottom lip on left side was noted to be swollen. The patient would not cooperate and allow nurse to examine his lip at that time. Later when wife and son were here he allowed the nurse manager to feel left side of his mouth. Wife stated that he had two (2) teeth in lower jaw which now are missing. It was not reported this a.m. that patient had fallen or that he had been injured. Patient could not tell if he fell or not. He did not comprehend. The patient ate 100% (percent) of his meal. It was very difficult to get patient to take his medications today. He was very argumentative.
At 4:45 p.m. an order was received for a scan of the head and x-ray of facial bones.
At 6:05 p.m. a wheelchair was brought to patient to take him for a CT (Cat Tomography) scan. He refused to sit in the wheelchair and walked to CT and x-ray. He walked very slowly and slipped a lot, but finally got there. He would not lie down on the CT table. After trying to get the patient to lie down for 15 minutes, he was escorted back to the unit. The CT and X-ray were done at a later time and no injury was identified.



A 9/18/15 Physician's consultation contained the following information:
"The patient is a [AGE]-year-old black male who was admitted to the Senior Care Unit for behavioral disturbances... apparently was admitted to nursing home... diagnosed with Alzheimer's dementia with behavior disturbances, peptic ulcer disease, and cerebrovascular disease. He was apparently becoming difficult to manage at the nursing home as well, having agitated behaviors and apparently hitting staff members and was subsequently admitted to this facility (9/15/15) for evaluation and treatment... he was noted on the morning of the 17th by the staff to have a swollen lower lip and little bit of red eye and apparently his family came to visit and also thought he had a couple teeth previously, which are no longer present and is not clear what happened... The patient is unable to give any real history about what happened to his lip, eye, or his teeth. He does not report a fall and had no witnessed falls. He does not appear to not have any real complaints of pain associated with it or any other injuries that have been able to ascertain by complaints of pain or injury. Physical Examination: I do not see any obvious swelling or signs of trauma. His pupils are round and reactive. Extraocular movements are intact. He has a little bit of redness in the left lateral sclerae and does not appear to be any subconjunctival hemorrhage type, it is still red. There are no inflammatory changes on his conjunctivae. Visual fields appear grossly normal with confrontation. Oropharynx, he does have a little swelling and a visible bruise on his lower lip to the left of the midline... He resisted exam, did not want me to look into his mouth. I could not visualize any teeth, but I did not see any obvious injury sites of bleeding or anything. His speech was clear... He was awake and alert for the most part cooperative, but quite confused. He did not know where he was. He thought he was at his brother's house and that he had been here for years. He told me, he was not aware of the date or the year and was having hallucinations during my exam, thought there were some other people in the room with us... after I finished my exam, we had walked out in the hall and he walked back in the room to get the other people out... Recommendations: We will monitor his status... to the lower lip for the swelling, but he does not particularly seem bothered by it at this time and may not allow that."



An interview with RN #2 on 10/15/15 at 1:55 p.m. revealed that she was the nurse that admitted Patient #1 to the Senior Care Unit on 9/15/15. His family did not accompany the patient to the hospital and the admission information was obtained during a telephone interview with the patient's wife. The wife said the patient had upper and lower dentures but had lost them. The patient was confused and did not like to be touched. On 9/17/15 the left side of his mouth and the left side of his eye were noted to be swollen a little. The doctor attempted to examine the patient's mouth but was unable because the patient would not let him do so. The doctor thought that the patient may have had a reaction to some medication he was on. She noticed that the patient seemed to have poor eyesight. "He would walk almost within distance of touching things, like the bathroom wall."


A telephone interview with RN #4 on 10/15/15 at 4:05 p.m. revealed that she was the charge nurse and Patient #1 was her patient on the night shift on 9/16/15. The patient was pacing and would not let staff do anything for him. The patient went into the nurses' station. She tried unsuccessfully to redirect him and he became belligerent. The patient said this was in his house and he could go anywhere in his house. The patient also went into the kitchen. Staff got MHT #2 to see if he could redirect the patient "because he is real good with patients". MHT #2 got the patient to his room, but he could not calm the patient down. RN #5 called the doctor, got an order to give the patient a shot, and gave him the shot. MHT #2 sat in the room with the patient until approximately 10:00 p.m. At that time RN #4 stayed with the patient and gave him some Doritos, which he ate. RN #4 stated that she got him calmed down enough that she no longer stayed with him, but went in and out of his room. Finally the patient lay down in his bed and she secured the bed alarm to his bed. RN #4 then went to assist another patient. When she finished she took Patient #1 up front. RN #4 stated that when RN #2 saw the patient she asked, "What's wrong with his mouth?" RN #4 stated that she had not noticed anything unusual with the patient's mouth prior to that time. She looked at his mouth and noticed that the left side of his lip was kind of fat. She then looked into his mouth and noted an ulcer in his mouth.


Review of the facility's "Vulnerable Person" policy (last revised/reviewed 3/15) revealed, "...Procedure: Reporting Requirements: Associates (employees) shall report any suspicion of abuse/neglect to their supervisors immediately. Abuse should be reported by the supervisor and/or Administrative Representative within 24 hours by phone and submit an online report. A written report should be submitted to the Mississippi State Department of Health/Licensure and Certification and Medicaid Fraud Control Unit within 72 hours. The written report shall contain the date and time of the alleged abuse in the narrative section, "State Reasons for Suspicion"."


The facility to provide a written report of a suspicion/complaint of physical abuse to the Mississippi State Department of Health within 72 hours for Patient #1.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on staff interview, facility investigation report review, and policy and procedure review, the facility failed to inform the patient's family of the resolution of the grievance filed on behalf of Patient #1, one (1) of nine (9) patients reviewed.


Findings include:


An interview with the facility's Risk Manager on 10/15/15 at 12:15 p.m. revealed Patient #1 was found to have two (2) teeth missing and a swollen lip on 9/17/15 by facility staff. The patient's family was not informed of the results of the facility's investigation. There was no indication that the cause of the injuries was ever determined.


Review of the facility's investigation report revealed:

Patient #1 was admitted to the Senior Care Unit from a local nursing home on 9/15/15 at 3:42 p.m. due to increased agitation and refusing to accept care at the nursing home. He was alert, but disoriented and required frequent redirection. At the time of admission, the admitting nurse asked the patient's wife if he had glasses and/or dentures. The wife said he wore glasses for reading only and did not have them with him and that he had lost his dentures. On 9/16/15 staff noted that the patient paced the unit for hours. He wandered in and out of empty rooms and other patients' rooms. It was reported by staff that the patient was difficult to re-direct, had disorganized thought processes and hallucinations, did not like to be touched, and appeared to have poor vision as he would walk up to solid objects (like a wall) without stopping. It was noted by staff on 9/16/15 that Patient #1 had two (2) lower teeth in his mouth, one on each side of his lower jaw.
On the morning of 9/17/15, when staff was preparing the patient for breakfast, it was noted his left eye was red and lip was swollen. The patient could not verbalize what had occurred and staff was not able to further assess because the patient would not allow them to look in his mouth. The RN immediately reported these findings to the Charge Nurse. When the psychiatrist made rounds just after 9:00 a.m. she examined the patient's lip and tongue and noted the lip swollen, but the tongue was not swollen. There was no indication that bleeding was noted. Her assessment was that this could be a possible reaction to Haldol and medication regimen was changed.
During family visitation on the afternoon of September 17, the wife and son of Patient #1 came to visit. The son came to the nurse's station and asked if a dentist had seen his dad. The son went on to say that his dad was missing his two teeth. The Nurse Manager and Program Director went to the patient's room. With the son in attendance, the Nurse Manager was able to examine the patient and noted the swollen lip and what appeared to be a hematoma on the inside of the lip, no teeth were noted and no bleeding was noted. The room was searched by nurse manager and program director at that time and no teeth, no evidence of blood was found.
On 9/17/15 the psychiatrist ordered a CT (Cat Tomography) scan of the head. Patient #1 refused, telling the staff that he was a "grown man". He kept telling the staff that his "dad took him to the dentist".


Review of the facility's "Complaint/Grievance Process" (Date Revised/Reviewed: 2/15) revealed: "...Policy: 1. Patients have the right to express concerns and expect resolution in a timely manner... 4. The Quality Improvement Council ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance,.... 6. If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that a follow-up written response will be provided within a specified time period but not to exceed 30 days until the frievance is resolved. If the grievance remains unresolved after 30 days, additional written follow-up would be indicated within a specificed time period but not to exceed an additional 30 days..."


The event was reported to Hospital Administration on the afternoon of 9/17/15 and an investigation was initiated at that time. The patient's family was not informed of the results of the facility's investigation. There was no indication that the cause of the injuries was ever determined.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure that the content of Patient #1's medical record consistently described the patient's progress and response to services. Patient #1 was one (1) of nine (9) patients reviewed.


Findings include:


Record review for Patient #1 revealed no nurse's note were written on 9/17/15 from 6:43 a.m. until 2:00 p.m. Nurse's Notes documented:
9/17/15 "6:10 a.m. the patient was hitting, kicking, punching staff and resistant to care. Feces was all over the patient. Two (2) MHT (Mental Health Technician) cleaned and dressed the patient."
9/17/15 "2:00 p.m. the patient was oriented only to himself. He was very confused, disoriented, and very difficult to direct. It was noted early this a.m. that the patient's sclera was red in the left eye. His bottom lip on left side was noted to be swollen. The patient would not cooperate and allow nurse to examine his lip at that time. Later when wife and son were here he allowed the nurse manager to feel left side of his mouth. Wife stated that he had two (2) teeth in lower jaw which now are missing. It was not reported this a.m. that patient had fallen or that he had been injured. Patient could not tell if he fell or not. He did not comprehend. The patient ate 100% (percent) of his meal. It was very difficult to get patient to take his medications today. He was very argumentative."


The time the patient's lip was noted by staff to be swollen, his teeth missing and left eye red was not documented in the nurse's notes. Nursing documentation did not show that the facility's policy to conduct a patient assessment at the beginning of the shift was followed on 9/17/15 by staff.


Review of the facility's "Charting/Documentation" policy revealed, "... C. Nursing service documentation is narrative and form charting. F. Patient assessments are done at the beginning of the shift and as patient condition warrants."


The lack of nursing documentation regarding Patient #1 on 9/17/15 from 6:43 a.m. until 2:00 p.m. was discussed with the Risk Manager on 10/16/15 at 11:30 a.m.