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Based on record review and interview, the facility failed to provide patient safety, in that, 1 of 10 patients (Patient #1) did not receive his Citalopram for his depression during his admission from 1/20/14 through 2/04/14.

Findings Included:

Patient #1's medication orders revealed the patient did not receive Citalopram. (Patient #1's documents received by HealthSouth upon the 1/20/14 patient transfer from the transferring hospital reflected the patient's Citalopram was held for the Pre-transfer orders but the Post-transfer orders included Citalopram as an active medication.)

Personnel #4 was informed that patient #1 had not received Citalopram. Personnel #4 confirmed the patient did not receive the medication. Personnel #4 explained the pharmacist completed the medication reconciliation at admission and that medication was not included in the Electronic Medical Record (EMR) for the doctor to review.

Based on record review and interview, the hospital failed to use the data collected during a grievance investigation to identify opportunities for improvement and changes that would lead to improvement, in that, 1 of 1 grievance investigation (2/12/14 grievance submitted for Patient #1) revealed:

1) Patient #1's weight bearing order differed from what was reported on the 2/04/14 discharge instructions to the receiving assisted living and rehabilitation provider;

2) Patient #1's discharge evaluation process did not reveal the need for a medical bed for the patient's return to an assisted living facility; and

3) the case manager did not provide for the durable medical supplies that were recommended for Patient #1's discharge on 2/04/14 to the assisted living facility.

Findings Included:

1) The 2/04/14 discharge instructions for patient #1 stated, "Safety and Wt (weight) bearing Special Inst (instructions): 50% on Right."

The 2/04/14 "Post-Surgical Follow-up" form for patient #1 stated 25% weight bearing and follow-up in three weeks.

During an interview on 5/01/14 at 4:00 PM, personnel #5 was asked about the difference in the physician order and the discharge instructions. Personnel #5 stated 50% was an error for this patient. Personnel #5 explained that during the complaint investigation the error was realized as well as the constraints of the electronic medical record.

The 4/16/14 Quality Council Minutes included Patient #1's complaint with "Action Plan: None needed." No discussion or details were documented.

During an interview on 5/01/14 at 4:30 PM, Personnel #1 was informed the quality council minutes reflected the grievance and no action needed. Personnel #1 confirmed the finding and stated the minutes should have included information on the findings of the investigation and any plan for improvement.
2) The 1/21/14 Case Management Initial Eval and/or subsequent case management notes for patient #1 did not document a verbal or physical assessment of the home environment the patient was expected to return to.

During an interview on 5/02/14 at 10:10 AM, personnel #7 said the medical bed did not come up in the assessment of needs for the patient.

During an interview on 5/02/14 at 11:30 AM, personnel #2 was asked about the grievance investigation. Personnel #2 said they investigated the issue and found the need for a bed was not assessed.

The 4/16/14 Quality Council Minutes included Patient #1's complaint with "Action Plan: None needed." No discussion or details were documented.

During an interview on 5/01/14 at 4:30 PM, Personnel #1 was informed the quality council minutes reflected the grievance and no action needed. Personnel #1 confirmed the finding and stated the minutes should have included information on the findings of the investigation and any plan for improvement.

3) The 2/04/14 discharge instructions for patient #1 stated, "DME (Durable Medical Equipment)...recommended: shower chair, tub bench...manual wheel chair..."


The 2/04/14 case management note reflected, "no new DME required."


During an interview on 5/02/14 at 10:10 AM, personnel #7 said the wheelchair was not provided.

During an interview on 5/02/14 at 11:30 AM, personnel #2 was asked about the grievance investigation. Personnel #2 said they investigated the issue and found the W/C was not provided.

The 4/16/14 Quality Council Minutes included Patient #1's complaint with "Action Plan: None needed." No discussion or details were documented.

During an interview on 5/01/14 at 4:30 PM, Personnel #1 was informed the quality council minutes reflected the grievance and no action needed. Personnel #1 confirmed the finding and stated the minutes should have included information on the findings of the investigation and any plan for improvement.

The April 2013 "Discharge Planning Overview" policy required, "To define the role in the initiation and implementation of the discharge planning process and to prepare for a realistic disposition which maximizes patient's independence, ensures safety, and continuity of care after discharge...Care and equipment will be ordered...Any outside service which will assume care of the patient will be provided with all information needed to assume that care...a home evaluation may be scheduled to identify and resolve potential problems..."

Based on record review and interview, the facility failed to counsel the family members on the discharge plan to prepare them for post-hospital care, in that 1 of 10 patient's (Patient #1's) family was not notified of the patient discharge.

Findings Included:

The medical record for patient #1 did not document family counseling of the patient prior to being discharged on 2/04/14.

During an interview on 5/02/14 at 10:10 AM, Personnel #7 was asked about the documentation of the discharge of Patient #1. Personnel #7 said she did not talk to the family about the discharge.