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Based on record review and interview the facility failed to implement it's grievance policy dated January 2010 to resolve patient complaints concerning quality of care and to inform them in writing the steps that were taken to investigate and resolve the complaint. The facility did not respond in writing to a family's complaints, citing one patient identified in a complaint TX 00142246. (Patient # 1).

Findings:

Review of complaint narrative written by Complainant J, on behalf of patient # 1 revealed the complainant had the following care concerns:

(a) Ninety eight (98) years old Patient #1, was given the drug Morphine(pain medication) which had a as needed (PRN) order without the patient asking for pain medications, as a result the patient became very drowsy and dizzy. According to the complainant the facility did not use good judgement.

(a) Staff did not respond in a timely manner when the patient called for assistance to the rest room.

(c) the patient fell out of bed and the bed alarm was not activated although the patient was labeled "high risk for fall".
(d) Complainant spoke to several different staff who told her they would look into her concerns,but no one ever responded.

During a telephone interview on 4/11/11 at 2:30 pm with complainant J, she stated she spoke with administrative staff regarding her concerns but to date no one had responded to her concerns.

Review of the hospitals complaint records revealed no documentation that the complainant had voiced concerns regarding the care and services patient # 1 received.

Review of admission record for patient # 1 revealed she was admitted to the facility on February 2011 and again in March 2011.

Review of nurses notes dated 2/11/11 revealed documentation that the "patient's niece had concerns regarding medication that her aunt was given because she was more confused as compared to earlier". Further review of progress notes and nurses notes for the February and March admissions revealed no documentation in the patient's record that patient or family had other care concerns.

Review of nurses notes dated February 15, 2011 revealed documentation that Staff # 50, "Chief Nursing Officer(CNO) was in the patient's room talking to her niece"

During the investigation the Surveyor verified that Complainant J discussed her concerns with unit and administrative staff,however no one responded to her concerns.

During an interview with Staff # 51, Quality Coordinator she stated Ms. J, ( Complainant) had a discussion with her regarding her dissatisfaction with the nursing staff giving Patient # 1 Morphine when it was not indicated. According to Staff # 51, the complainant stated she felt Morphine was given to the patient to keep her sedated so staff would not have to take her to the rest room during the night.
Staff # 51 also stated the complainant told her that staffs were also putting the patient in diaper and her aunt never wore diapers before.

During an interview on 4/12/11 with Staff # 52, Nursing Director she stated she remembered having several discussions with Patient # 1's niece who had concerns regarding her Aunt ' s care.

During an interview on 4/12/11 at 11:45 am at the facility with Staff # 50 (CNO) she stated Complainant J , made a complaint to her, that the patient was given Morphine which made her dizzy and that she was never given morphine for her pain before and that the patient did not ask for any pain medication.
According to Staff # 50 she investigated and found there was a PRN (give as needed) order for the morphine. There was also documentation that the patient was in pain. The CNO further stated she did not document the complaint or the investigation and did not respond to the complainant in writing because the patient was an in- patient and the concerns were not considered a grievance.

Review of the facility's grievance policy dated January 2010 revealed that:
"A patient grievance is a formal or informal written or verbal complaint that is made when a patient issue cannot be resolved promptly "on the spot" by staff present. Within 7 days of the grievance , a letter will be submitted to the complainant that includes results of the grievance investigation, corrective action as necessary."
The facility failed to respond to Complainant J in writing.

Based on record review and interview the facility failed to ensure that a patient's condition was assessed when she was found lying on the floor in her room; failed to assess for adverse effects after medication was administered per the facility's protocol.
The facility failed to provide documentation that the physician was informed when a patient was found on the bathroom floor in his room.
The facility failed to follow their fall protocol to document incidents of falls in the patient's clinical record, citing two (2) of four (4) sampled patients that fell in the facility.

Findings:

During a pre investigation telephone interview on 4/11/11 with Complainant J, she informed the Surveyor that Patient # 1 was admitted in the facility in March 2011 and she arrived at the hospital one morning and was informed the patient was found on the floor.
According to Ms. J ,she spoke with the nurses and found out that prior to the fall, despite the fact Patient # 1 was on "fall alert" the bed alarm was never activated.
According to Complainant J, Patient # 1 had a "large bruise on her shoulder and along her rib cage which remained tender to touch for a long time". According to the complainant she was not aware that an X-ray of the patient's shoulder was ever done to determine if there was a fracture.

Review of facility ' s fall reduction policy dated November 2010 revealed the following information:

The "scope is to effectively identify patients who were at risk for falls, to prevent patient falls and protect patients from injury and to enhance patient safety. All patients are assessed after a fall and the physician notified. Determine level of injury. If unable to determine level of injury at time of the fall, do so with a follow-up of event.
The assessment is documented in the patient ' s medical record".
The policy did not clearly instruct staff to conduct a follow up assessment of patients when they fall to ensure that any missed injury at time of initial assessment does not go undetected in order to promote patient safety.

Patient # 1

Review of Emergency Room(ER) records revealed Patient # 1 presented to the ER on 3/18/11 with complaints of lethargy for over a week. She had not had much of an appetite for the past few days. B/P 135/72, Pulse 59, respiration 18. She was oriented to person only.
She was admitted to the unit where a physician ' s history and physical was completed. The physician diagnosed that the patient had Altered Mental Status and generalized weakness.

Review of the nurses admission notes dated 3/18/11 at 2314 pm documented the patient was coherent but confused and forgetful at times. At 1849 pm there was documentation that the patient was in bed and was on fall risk.

Further review of the nurses ' notes revealed that on 3/23/11 at 0111 an order for CT(Computerized Tomography) of head was made by the physician.

Subsequent nursing documentation revealed documentation that bed alarm was on.
Prior to 3/23/11 at 0301 there was no documentation that the patient ' s bed alarm was on, however there was continuous documentation that the patient was confused and forgetful.

There was documentation that Patient # 1 was discharged from the facility on the evening of 3/24/11.
There was no documentation that the patient was found on the floor in her room, nor that the patient was evaluated for injury. There was no documentation of a follow up assessment.

There was documentation that in the early morning of 3/23/11 the physician ordered a CT of head but no mention the patient fell.

The physicians ' discharge summary dated 3/25/11 documented the patient had an episode of fall and had a CT of head which showed no abnormality.

Review of incident reports for fall revealed there was a fall risk worksheet that was initiated which stated the patient was found lying on the floor next to her bed. There was no assessment documented on the form or medical record. The fall incident was never mentioned on the patient's medical record.

Review of nurses dated 2/13/11 revealed documented that at 2325 pm patient # 1 was "still not asleep restless, given Xanax ( sedative) to calm her down".

Review of nurses notes dated 2/14/11 at four (4) minutes past midnight revealed documentation that Patient # 1 complained of a " dull pain in her back, especially when she moves " B/P 164/87, heart rate 85, will give pain medication".
Documentation at 19 minutes after midnight revealed the patient was given 4 mg of Morphine IV.( less than an hour after the sedative xanax was administered).
There was no documentation that the patient was ever re assessed for any adverse effects of the Morphine or Xanax.

Review of the facility's Pain Management Policy revised April 2010 documented that the policy's goal is to:
" assess, evaluate and manage patient's level of pain upon admission and through out the hospital stay". The policy documented there would be assessment after each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect". There was no documentation that the patient was assessed after the administration of a sedative and pain medication.

Patient # 2

Review of clinical record for Patient # 2 revealed she was 59 year old female admitted to the facility on 2/8/11. Her chief complaint was syncope several times in the past 5 days especially when getting up.
There was documentation dated 2/11/11 at 1310 that the patient was found sitting on the bathroom floor. She was assisted back to bed. There were no injuries, vital sign blood pressure (B/P) 108/77, and pulse 89. The patient denied pain. Call light placed within reach. Red socks applied instructed to call for assistance. Will monitor.
There was no documentation that the physician was informed or that the staff re-assessed the patient.

During an interview on 4/12/11 with Staff # 53, Director of Risk Management regarding the allegations of patient falling out of bed, she stated she was not aware the patient had fallen until the Surveyor mentioned it. She presented a fall incident which she stated was initiated but was not completed according to the facility ' s protocol for completing a fall risk assessment.
Staff # 53 further stated that staff were required to assess all patients after medication is administered. She also stated it is expected that all patients are re-assessed after a fall to ensure no injury was missed.