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Based on one (#1) of six (#1-#6) clinical record reviews, review of complaint allegations, review of the policy and procedure on medical records, interview with Physicians #6 and #3 and the Chief Clinical Officer, it was determined that physician #6 failed to follow the agency's policy on Medical Records resulting in Patient #1 receiving Heparin (used to prevent the formation of blood clots) for two days ordered by physician #3 because physician #6 failed to document the allergic reaction to Heparin, after informing the Complaint that the Heparin would be stopped while discussing the changes in the plan of care.

The findings includes:

Patient #1 was admitted to this Long Term Acute Hospital on January 21, 2011, from a non local hospital. At that hospital a hemicolectomy (a partial colon resection) was performed and was ventilator dependent due to respiratory failure. February 8, 2011, Patient #1 was transferred to a local hospital's emergency room for potential emergent dialysis treatment for renal failure. Patient #1's potassium was 7.4 on transfer to the local emergency room (Normal potassium lever is 3.5-5.0), on February 7, 2011, at 10:00 p.m..

Results of this admission revealed a hyperkalemia (high blood potassium) was due to Heparin administration, dehydration and na Urinary Tract Infection. The General Medicinal Progress notes, dated February 8, 2011, stated the dehydration was due to Gastrointestinal losses from C diff. (Clostridium difficile is a bacteria in the intestinal tract. Under certain conditions, it causes diarrhea and sometimes severe disease. The severe form of the disease is known as pseudomembranous colitis (often call C. diff colitis). and IV RTA (The allergy to Heparin). Heparin was discontinued for Patient #1 prior to being readmitted to Kindred Hospital on February 12, 2011.

Physician #6 was the person who admitted Patient #1 to Kindred Hospital on February 12, 2011. A discussion was done according to the complaint allegations to have the Heparin listed as an allergy. Physician #6 failed to list Heparin as an allergy. The complaint allegations stated, "It was discovered by the pharmacist that my mother had been given Heparin since the previous Monday, two days after she was transferred back from ... (The local hospital), even though her records clearly stated that she was NOT to have this medication and even after my husband and I had personally discussed with Physician #6 that previous Saturday." Physician #6 failed to adequately document Patient #1's response to Heparin and listing it as an allergy on her medical record. More importantly. Physician # 6 failed to communicate either verbally or in Patient #1's progress notes of her reaction to Heparin for all future physicians to be alerted. Physician #6 was interviewed, via telephone,about this incident, but denied remembering anything specially about the Heparin. This interview occurred on March 27, 2012, at 14:05 p.m. Physician #6 failed to ensure that Patient #1's family participated in the plan of care.
Physician #3 stated that he reordered the Heparin in order to prevent Patient #1 from having a pulmonary embolus.

The policy under Medical Staff Rules and Regulations for Medical Records stated, "The responsible practitioner shall be responsible for the preparation of a complete medical record for each patient. The content of the medical records shall be pertinent and current." Patient #1 received Heparin for two days until the Interdisciplinary team reiterated that Heparin was an allergy for Patient #1, stated the Director of Clinical Services, on February 27, 20012, during interview. This interview occurred on March 27, 2012, in the conference room, at 4:34 p.m. These allegations were substantiated.

Based on review of the adverse event report, review of clinical record #1 and interview with Director of Clinical Services, it was determined that one (#1) of six clinical record reviewed contained documentation Patient #1 sustained a fall while a patient at Kindred Hospital resulting in a laceration to the forehead needing sutures from a local emergency room.

The findings included:
The skilled nursing notes dated 2/20/11 stated that Patient #1 was found on the floor approximately 8:00. Physician ' s progress notes stated Patient #1 had a laceration on her forehead. Another trip to the local emergency room for sutures was initiated. The hospital failed to ensure that Patient #1 was in a safe environment.
T he Adverse Event report stated that Patient #1 had sustained a fall on 2/20/11. Interview with the Director of clinical services verified that Patient #1 had a fall on 2/20 11. This interview occurred in the agency ' s conference room, on 3/2712 in the agency ' s conference room.

Based on one (#1) of six (#1-#6) clinical record reviews, review of the policy and procedure on medical records, interview with Physicians #6 and #3 and the Chief Clinical Officer, it was determined that physician #6 failed to follow the agency's policy on Medical Records resulting in Patient #1 receiving Heparin (used to prevent the formation of blood clots) for two days ordered by physician #3 because physician #6 failed to document the allergic reaction to Heparin and failed update the progress notes so that oncoming physicians would be aware of the change in condition of Patient #1 with regards to the Heparin usage.

The findings includes:

Patient #1 was admitted to this Long Term Acute Hospital on January 21, 2011, from a non local hospital. At that non local hospital a hemicolectomy (a partial colon resection) was performed and was ventilator dependent due to respiratory failure. February 8, 2011, Patient #1 was transferred to a local hospital's emergency room for potential emergent dialysis treatment for renal failure. Patient #1's potassium was 7.4 on transfer to the local emergency room (Normal potassium lever is 3.5-5.0), on February 7, 2011, at 10:00 p.m..

Results of this admission revealed Hyperkalemia (high blood potassium) due to Heparin administration, dehydration and an Urinary Tract Infection. The General Medicinal Progress notes, dated February 8, 2011 was due to Gastrointestinal losses from C diff. (Clostridium difficile is a bacteria in the intestinal tract. Under certain conditions, it causes diarrhea and sometimes severe disease. The severe form of the disease is known as pseudomembranous colitis (often call C. diff colitis). and IV RTA (The allergy to Heparin). Heparin was discontinued for Patient #1 prior to being readmitted to Kindred Hospital on February 12, 2011.

Physician #6 was the person who admitted Patient #1 to Kindred Hospital on February 12, 2011. A discussion was done according to the complaint allegations to have the Heparin listed as an allergy. Physician #6 failed to list Heparin as an allergy. The complaint allegations stated, "It was discovered by the pharmacist that my mother had been given Heparin since the previous Monday, two days after she was transferred back from ... (The local hospital), even though her records clearly stated that she was NOT to have this medication and even after my husband and I had personally discussed with Physician #6 that previous Saturday." Physician #6 failed to adequately document Patient #1's response to Heparin and listing it as an allergy on her medical record. More importantly. Physician # 6 failed to communicate either verbally or in Patient #1's progress notes of her reaction to Heparin for all future physicians to be alerted. Physician #6 was interviewed, via telephone,about this incident, but denied remembering anything specially about the Heparin. This interview occurred on March 27, 2012, at 14:05 p.m. Physician #6 failed to ensure that Patient #1's family participated in the plan of care.
Physician #3 stated that he reordered the Heparin in order to prevent Patient #1 from having a pulmonary embolus

The policy under Medical Staff Rules and Regulations for Medical Records stated, "Pertinent progress notes shall be recorded at the time of observations, not via access of the electronic medical record. Whenever possible, each of the patient's clinical clearly identified in the progress notes and correlated with the specific orders as well as results of tests and treatments. Progress notes shall be written at least daily on all patients documenting changes, updates and modifications to the treatment plan." Patient #1 received Heparin for two days until the Interdisciplinary team reiterates that Heparin was an allergy for Patient #1, stated the Director of Clinical Services, on February 27, 20012, during interview. This interview occurred on March 27, 2012, in the conference room, at 4:34 p.m. These allegations were substantiated.

Based on staff interview, clinical record reviews and findings from a bronscopy report and the discharge summary from a local hospital, It was determined that one (#1) of six (#1-#6) patients failed to have the tracheotomy (An opening through the neck into the windpipe through which a tube may be inserted for breathing) tube inserted correctly by a skilled nurse, resulting in an admission to the local hospita1 for Patient #1.
The findings included:
1. RN #6 was interview on March 29, 2012, at 08:40 a.m., in the agency ' s conference room. After reading the nursing notes, RN #6 could not recall the incident or Patient #1 because this was greater than a year since this had happened.
2. Physician #16 stated that there was a blockage to the trachea that appeared to be due to a granulation tissue, as documented in his progress notes. Suctioning was applied in an attempt to remove any secretions. No significant secretions were removed. The disposition was that Patient #1 would be transferred to a local hospital where the blockage of trachea can be addressed and corrected. This physician ' s progress notes were dated February 01, 2011, at 10:14 a.m.

Another bronscopy was performed at the local hospital on February 2, 2011, at 6:03 a.m. "Branch demonstrated trachea in false passage. Stoma to trachea closed. Nasotracheal endoscopy revealed patent trachea without evidence of stenosis and infection. Procedure done by interventional pulmonary service under conscious sedation. Pt (Patient #1) will recover in ED and be discharged back to care facility. Tracheotomy removed and cite covered. The skilled nurse failed to adequately place the tracheotomy tube in the correct place resulting in it being in a false passage, enduring two bronscopies and an admission to a local hospital.