HospitalInspections.org

Based on interview and record review, the facility failed to ensure grievances were investigated and acted upon in 2 of 12 sampled patients ( Patient #'s 2 and 3).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of a personnel file revealed the following information recorded:

"Reason for Disciplinary Action/Facts related to Incident:
Date of occurrence ( If applicable): Final Written Warning: 8/2/16- 2 patients complained that RNT(rehab nurse tech) was rough in transfers. One was witnessed by spouse of patient and the other was witnessed by Nurse Manager (Staff #10), and an additional staff member. The first patient's spouse reported that the patient was transferred in bare feet and (Staff #8) stood by with her arms on her hips and told patient he needed to learn to transfer himself. As the wife attempted to help the patient pull down his pants in the bathroom, Staff #8 told her to stop because "he needs to learn to take care of himself." The second patient is a max assist with transfers. Staff #8 was very impersonal and told the patient, "you are going to lean forward." She did not offer to assist patient. The patient needs encouragement and she did not receive that from Staff #8. Both patients requested that RNT not be allowed to return to their rooms. This is not acceptable care of our patients. This behavior is not tolerated. Staff #8 has been re-educated on providing appropriate patient care and is knowledgeable of safe handling of patients."

Review of the facility complaint and grievance logs from January 2016 to January 2017 revealed no documentation of either incident.
There was no documentation of interventions taken to notify the complainants of what was being done to address their complaints. There was no written notification provided.
Staff #2 confirmed the incidents were not on the complaint and grievance log. They could not find documentation of the investigation of the incidents. No written notification was provided.
Review of the facility's "Patient and Customer Complaint or Grievance" policy date 3/3/2015 revealed the following:

"All complaints must be recorded in the hospital complaint log. The entry into the log must include:
*date received
*nature of complaint
*who responded
*action taken
*date and shift of resolution
Patient Grievances
Not all complaints will meet the criteria of a grievance. Complaints meeting any of the criteria below are considered grievances and require a written response.
2. Complaint regarding the patient's care or with an allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more COPs, or other CMS requirements, ...

Patient Grievances- Actions to be taken
The hospital must review, investigate and resolve each patient's grievance within a reasonable time frame and provide a written response. Grievances involving situations that potentially endanger the patient such as neglect or abuse should be reviewed immediately.

3. A written communication must be sent to the patient( or patient ' s legal representative), even if other methods of communication are used (such as a family meeting). On average, the written response should be complete within 7 calendar days of receipt of grievance .....
j. If hospital CEO or designee determines the investigation is not or will not be completed within 7 calendar days, he/she must provide patient/family with a verbal or written progress report. Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days ...
7. All grievances must be recorded in the hospital grievance log ..."

Based on interview and record review, the facility failed to ensure written notification was given to patients or families regarded grievances about care in 2 of 12 sampled patients ( Patient #'s 2 and 3).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of a personnel file revealed the following information recorded:

"Reason for Disciplinary Action/Facts related to Incident:
Date of occurrence ( If applicable): Final Written Warning: 8/2/16-2 patients complained that RNT(rehab nurse tech) was rough in transfers. One was witnessed by spouse of patient and the other was witnessed by Nurse Manager (Staff #10), and an additional staff member. The first patient's spouse reported that the patient was transferred in bare feet and (Staff #8) stood by with her arms on her hips and told patient he needed to learn to transfer himself. As the wife attempted to help the patient pull down his pants in the bathroom, Staff #8 told her to stop because "he needs to learn to take care of himself." The second patient is a max assist with transfers. Staff #8 was very impersonal and told the patient, "you are going to lean forward." She did not offer to assist patient. The patient needs encouragement and she did not receive that from Staff #8. Both patients requested that RNT not be allowed to return to their rooms. This is not acceptable care of our patients. This behavior is not tolerated. Staff #8 has been re-educated on providing appropriate patient care and is knowledgeable of safe handling of patients."

Review of the facility complaint and grievance logs from January 2016 to January 2017 revealed no documentation of either incident.
There was no documentation of interventions taken to notify the complainants of what was being done to address their complaints. There was no written notification provided.
Staff #2 confirmed the incidents were not on the complaint and grievance log. They could not find documentation of the investigation of the incidents. No written notification was provided.
Review of the facility's "Patient and Customer Complaint or Grievance" policy date 3/3/2015 revealed the following:

"All complaints must be recorded in the hospital complaint log. The entry into the log must include:
*date received
*nature of complaint
*who responded
*action taken
*date and shift of resolution
Patient Grievances
Not all complaints will meet the criteria of a grievance. Complaints meeting any of the criteria below are considered grievances and require a written response.
2. Complaint regarding the patient ' s care or with an allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more COPs, or other CMS requirements, ...

Patient Grievances- Actions to be taken
The hospital must review, investigate and resolve each patient's grievance within a reasonable time frame and provide a written response. Grievances involving situations that potentially endanger the patient such as neglect or abuse should be reviewed immediately.

3. A written communication must be sent to the patient( or patient's legal representative), even if other methods of communication are used (such as a family meeting). On average, the written response should be complete within 7 calendar days of receipt of grievance .....
j. If hospital CEO or designee determines the investigation is not or will not be completed within 7 calendar days, he/she must provide patient/family with a verbal or written progress report. Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days ...
7. All grievances must be recorded in the hospital grievance log ..."

Based on observation, interview, and record review, the facility's nursing staff failed to supervise and evaluate the reconciliation of home medications on admission for 12 of 12 patients (Patient #'s 1-12).

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


Review of the nursing admission assessment on Patient #1 revealed she was admitted to rehab on 01/23/2017.
Review of the admission assessment revealed no documentation of home medications being listed or reconciled by nursing on admission.


During an observation on 02/01/2017 after 10:10 a.m., Staff #6 went over discharge instructions for Patient #1. Staff #6 instructed Patient #1 she was to take the same medications she was on at home. Patient #1's spouse asked which ones was she supposed to take. Staff #6 informed him they were to be taken the same way they were taken at home. Patient #1's spouse informed the nurse that Patient #1 had been off her home medications since December 5, 2016. Staff #6 left the room and went to talk to the physician about the medications. Staff #6 returned and went over the medications with Patient #1. Patient #1's spouse read from his list of home medications the patient was on to compare with the nurse's list. Patient #1's spouse read from his list that a pain medication was being taken every 6 hours at home and Staff #6 (nurse) read from her list that it should be taken every 4 hours.


Review of charts on Patient's #'s 2-12 revealed no documentation of the home medications being reconciled by nursing staff on admission.

Staff #'s 2 and 10 confirmed nursing was not documenting the home medications on the initial assessment. If the patient came in with bottles of medications or orders they were sent to pharmacy to reconcile and to list them on the medication administration record.


Review of a facility's policy dated November 2016 named "ADMISSION INFORMATION PROCEDURE" revealed the following:

"C. Information required for admissions from home:

2. The patient, if possible, must also bring an accurate list of their medications or the medications themselves for review by the admitting nurse.

3. If the patient medications are unavailable on admission the admitting nurse will call the patient's pharmacy for a list of current medications."




Review of a facility policy dated November 2016 named "ADMISSION OF PATIENT TO THE UNIT" revealed the following:

"K. The RN will complete the Admission Forms on the task list of the EMR with the assistance of the LVN which includes:
9. Medication Reconciliation

O. Medication reconciliation will be completed by pharmacy and the admitting RN and appropriate forms attached and a copy sent to the pharmacy by the patient's assigned nurse or Unit Clerk."