HospitalInspections.org

Based on document review and interview, the facility failed to ensure the Notice of Patient Rights was provided to each patient or their representative for 2 of 9 medical records (MR) reviewed (Patients #2 & 6).

Findings include:

1. Review of the policy/procedure Admission Process (revised 2-18) indicated the following: "The essential elements in the admissions process include... providing a complete admissions documentation package to the patient and/or legal representative and obtain the necessary signatures... The required Inpatient Admissions Forms are... iii. Patient Rights and Responsibilities..."

2. Review of the MR document titled Acknowledgement of Receipt of Health Care Information for Patients #2 and #6 lacked documentation indicating a copy of the Patient Rights and Responsibilities had been provided to the patient or their representative and signature of receipt obtained by a facility staff.

3. On 3-7-18 at 1430 hours, the Chief Clinical Officer, staff A3 confirmed the MR for Patients #2 and #6 lacked documentation indicating the notice of Patient Rights and Responsibilities was provided and signature obtained at the time of registration.

Based on document review and interview, the facility failed to follow its policy/procedures for documenting and reviewing an adverse patient event for 1 of 7 patient events (Patient #1) reviewed.

Findings include:

1. Review of the policy/procedure Risk Management Plan (revised 12-16) indicated the following: "All unusual occurrences are to be reported by employees through the online reporting system Q Solutions...an unusual occurrence report must be completed before the end of the shift... if the occurrence involves a patient, objective clinical observations and actions taken... are precisely documented in the medical record..."

2. Review of the MR for Patient #1 on 2-5-18 indicated the patient reported not feeling "right" and was observed to be lethargic, drowsy and pale for a significant part of the day. The MR indicated the patient was observed by their Registered Nurse, staff N11 and evaluated on several occasions by the Physician MD11 for a change in status before Narcan (naloxone) was administered by IV route with immediate arousal and agitation noted.

3. Review of incident reports for the period around 2-5-18 failed to indicate an event involving Patient #1.

4. On 3-7-18 at 1115 hours, the Director of Pharmacy, staff A7 confirmed that no medication incident or ADR (adverse medication reaction) of the event on 2-5-18 involving Patient #1 had been submitted or reviewed.

5. On 3-7-18 at 1430 hours, the Chief Clinical Officer, staff A3 confirmed that no incident report documentation for the event involving Patient #1 was available.

Based upon document review and interview, the Registered Nurse failed to supervise and evaluate the care provided to each patient for 1 of 9 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Medical Records Documentation Requirements (revised 12-16) indicated the following: "All medical records will contain documentation to substantiate care and treatment provided."

2. Review of the MR for Patient #1 indicated the following orders on 1-20-18 at 2100 hours: "alternate foot drop boot every two hours."

3. Review of the MR for Patient #1 lacked documentation indicating the foot drop boot was removed from one foot and placed on the alternate foot every two hours.

4. On 3-7-18 at 1430 hours, the Chief Clinical Officer, staff A3 confirmed the MR lacked documentation indicating the foot drop boot was removed and replaced as ordered.