The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|MEDINA MEMORIAL HOSPITAL||200 OHIO STREET MEDINA, NY 14103||July 24, 2018|
|VIOLATION: POLICIES - MED ERRORS & ADRS||Tag No: C0277|
|Based on policy review, document review, medical record review and interview, the nursing staff did not document medication error incidents in the medical record per facility policy for 2 of 3 patients(Patient #6 and #7).
Review on 07/24/18 of policy "Incident Reports and Investigations" last revised 03/18 indicates that medical record documentation should include a factual account of the incident, date and time that the provider/supervisor/family were notified, follow up care, observations and response to treatment.
Review on 07/24/18 of the Facility Quality Assurance Event Log from 12/23/17 to 05/20/17 revealed 25 medication events. Three of these events were randomly selected and tracked through quality assurance process.
Medical record review on 07/24/18 revealed no documentation of the medication error incidents that occurred on 05/14/18 for Patient #6 and on 12/26/17 for Patient #7.
Interview on 07/24/18 at 01:00 PM with Staff (E), Directotr of Quality Assurance, verified the lack of medical record documentation of the medication error incidents.
|VIOLATION: RESIDENTS RIGHTS (483.10(B)(3))||Tag No: C0361|
|Based on medical record review and interview, the facility did not provide a written copy of Resident Rights to the patient when their status changed from hospital inpatient to swing bed status in 2 of 2 patients (Patient #3 & 4).
Concurrent medical record review for Patient #3 and Patient #4 revealed no evidence that either patient received a copy of the "Residents Bill of Rights" when their status changed from hospital inpatient to a swing bed admission.
Interview on 07/24/18 at 01:00 PM with Staff (E), Director of Quality Assurance revealed swing bed patients receive the "Hospital Patient Bill of Rights". "The Resident Bill of Rights" is not provided to patients when their status changes from hospital inpatient to "swing bed" patient. The facility was unaware that there are "Resident Bill of Rights" for swing bed patients.