HospitalInspections.org

Based on observation, staff interview, admission packet and marketing brochure review; the facility failed to ensure patients and families were informed of the state complaint hotline contact information. This had the potential to affect all individuals who present to the rehabilitation hospital. The active census was 17.


Findings include:


Review of the Grievance Policy for Patient Rights and Responsibilities; Policy ID: 1174275 states upon admission verbal and written information will be given to patient and families regarding contact information for the State Department of Health.


Review of the admission packet included the Patient Rights and Responsibilities and a marketing brochure. Thorough review of the packet determined the State Hotline phone number was not included in either the admission packet and/or the brochure. Staff A stated that he/she was not aware of any document patient's are currently receiving that contain the state hotline contact information.


In addition, the rehabilitation unit was toured on 11/23/15 at 12:15 PM and observations revealed the unit lacked signage for Patient Rights and the state hotline complaint contact information. Staff A stated new Patient Rights signage was ordered and to be posted throughout the rehabilitation unit reflecting the facility name change. Review of the new Patient Rights signage was in the administration area in boxes; however, the new signage lacked the state hotline contact information. Staff A stated the facility was unaware patient's were not receiving the information on how to notify the state agency for complaints and/or grievances.

Based on medical record review, policy review, and staff interview it was determined the facility failed to complete incident reports and provide additional interventions following a patient fall. This affected two (Patient's # 6 and #10) of ten medical records reviewed. The facility census was 17.


Findings include:

1. Review of the Fall Prevention Policy for Patient Care- Care Coordination; Policy ID 1679822 states upon admission patients are assured of assessment of their risk of falls, manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. Further, an incident form is to be completed following a fall. The Chief Quality Officer will provide trends for the use in the reduction of falls.

2. Review of the medical record for Patient #6 revealed the patient was admitted to the facility in September 2015 for rehabilitation after suffering a stroke. On admission, the patient was identified as not being a fall risk. On 09/12/15 at 8:30 AM, the patient had a fall in his/her room. The registered nurse completed a " post-fall assessment " and the physician and family were notified of the fall. The patient did not sustain any injuries.

On 11/24/15 at 12:15 PM an interview was conducted with the CNO (Chief Nursing Officer) who stated that an incident report is to be completed for every patient fall. At 4:00 PM, the CNO confirmed that an incident report was not completed for the patient fall on 09/12/15.

3. Review of the medical record for Patient #10 revealed an admission to the facility on 08/10/15 for rehabilitation following a cerebrovascular accident. Upon admission it was noted the patient had right hemiparesis and severe expressive aphagia. The patient was admitted to the rehabilitation requiring total assistance for his self care needs, bowel and bladder management, transfers, ambulation, verbal expression, problem solving, and memory. He was at a maximum assist level for eating and required the use of a wheelchair.

The medical record confirmed the patient had three falls while on the rehabilitation unit (08/12/15, 08/15/15 and 08/17/15). The medical record documentation stated the patient would attempt to self transfer from the wheelchair to the bed and/or the bathroom without calling staff for assistance.

4. Review of the fall policy states the facility uses a Morse Fall Scale to determine a fall score for each patient. If a patient scores higher than one hundred the facility then implements high risk fall precautions. Based on the findings of the post fall assessments, the fall risk score failed to be higher than one hundred (99) following a fall. The medical record included a post fall assessment; however, failed to include additional interventions and/or proper fall occurrence management. Staff A confirmed on 11/24/15 at 4:00 PM a post fall incident report was not documented for the fall that occurred on 08/15/15.