HospitalInspections.org

Based on interview, review of policy, and record review, the facility failed to ensure each patient (Patient #1), or the patient's representative's right, to participate in the development and implementation of his or her plan of care.

Findings were:

During an interview on the afternoon of 8/8/2023, the CEO, Vibra Rehabilitation Hospital of Amarillo, who is also the former CEO, Vibra Hospital of Amarillo, (Staff #1) provided a "Grievance Investigation and Resolution" form and stated she did not know if the report had been finalized. A summary of investigative findings included: " ... (Patient #1's family members) were not notified of patient #1's change in condition. The form, dated July 12, 2023, indicated that the "issue was not resolved to the satisfaction of the complainant" and that "further investigation was warranted".

In review of the Vibra Healthcare (Hospital Wide) policy, "Change in Condition", last reviewed December 2022, the policy does not address notification of the patient's family member(s) and medical power of attorney, if applicable. According to the facility-wide policy: "The following could describe a significant change in patient condition. This list is not meant to exclude other possibilities, but rather to describe a significant change in condition and requires assessment, documentation and notification ... Change in mental status: level of consciousness (LOC), neurological status. Examples: Decrease LOC: New onset confusion, delirium, new paresthesia, weakness, paralysis ... Change in respiratory rate or increased work of breathing ..."

In further interview on the afternoon of 8/8/2023, Staff #1, former CEO, Vibra Hospital of Amarillo, stated: "I remember speaking with the House Supervisor, Staff #2. Staff #2 responded that he thought the bedside nurse(s), Staff #'s 3 and 4, had notified the family. Staff #2 received a reprimand. Staff #4 received training, as well. Nurse Practitioners sometimes notify the family; however, in this case, the NP did not notify the family ..."

Review of the archieved electronic medical record revealed Patient #1 experienced change(s) in his condition after his return to the facility following laparoscopic cholecystectomy. Changes to Patient #1's condition included but were not limited to: anoxia (an absence or deficiency of oxygen reaching the tissues); decreased oxygen saturation levels requiring the administration of supplemental oxygen; placement of a nasogastric tube for nutritional support (unable to take food by mouth); lethargy; inability to respond to questions; some weakness to the right hand. Neither patient #1's medical power of attorney nor any family member were contacted and made aware of his change(s) in condition and offered an opportunity to participate in treatment plan decisions.