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Based on record review and interview the facility failed to inform a patient and family of the steps taken to investigate an incident and the outcome of the investigation, when a patient was given wrong medication that was prescribed for another patient. Citing one (1) patient named in a complaint. Patient # (1).

Findings:

Review of complaint narrative revealed allegations Patient # (1) was given eight (8) medication that was prescribed for another patient which resulted in abnormal vital signs and he had to be transferred for higher level of care.

There was allegations the patient was filthy during his hospital stay because facility staff did not give him baths.
In the complaint there was allegation the facility staff did not contact the patient or family after he was transferred from their facility.

Nursing notes dated 7/1/2014 reveal documentation that at "08:54 patient was seen in the Common area eating. The patient was given the wrong medication. At 09:25 am the patient's Physician was informed of the error and he instructed to monitor patient every 15 minutes.
At 09:50 the physician was again contacted due to "drop in patient's pulse and blood pressure". The doctor instructed to start IV bolos 200 cc and to send the patient out".
Review of nursing documentation (no time) revealed information that "vitals dropped at extreme rate" (there was no information of actual measurement of vital signs).Patient was transported to an Acute Care Hospital. Family notified at 12 noon. Family member angry and stated "he won't be coming back to your facility.


During an interview on 9/10/2014 at 9:15 am with a named person in the complaint (#G) she stated the facility did not contact the family or the patient since the incident of wrong medication. Person (G) stated family complained to the facility on multiple occasions that Patient (#1) was not given a bath.
Person (G) stated she expressed her dis- satisfaction regarding the wrong medication incident by telling the nurse "heads were going to roll"

During an interview on 9/5/2014 at 10:12 am at the facility with Staff (A) Quality Director she stated the facility did not contact the patient or his family . She stated it was an oversight that would be addressed.

Review of the facility's Grievance Policy/Procedure HW-205 dated 4/2012 documented the purpose of the policy is:

"To establish a process for prompt and effective resolution of patient's families and visitors complaints and grievances".
The policy documented that:

"The grievance will be investigated by hospital leadership. Upon resolution of the issue the CEO shall provide to the patient or patient representative , written communication."

Based on record review and interview the facility failed to analyze the circumstances that allowed a nurse to administer eight(8) different medications to the wrong patient, which resulted in the patient being transferred to an acute care hospital with unstable vital signs. This failed practice had the potential for similar incident to occur. Citing one(1) patient named in a complaint. Patient (#1).

Findings:

Review of complaint narrative revealed allegations Patient # (1) was given eight (8) medication that was prescribed for another patient which resulted in unstable vital signs and he had to be transferred out for higher level of care.

There was allegations the patient was filthy during his hospital stay because facility staff did not give him baths.
Review of admission assessment notes revealed Patient # (1) was admitted to the facility for rehabilitative care after he fell and lacerated his skull. The patient had a diagnoses of Alzheimer Disease, with multiple notations that he was forgetful and confused at times.
Nursing notes dated 7/1/2014 reveal documentation that at "08:54 patient was seen in the Common area eating. The patient was given the wrong medication. At 09:25 am the patient's Physician was informed of the error and he instructed to monitor patient every 15 minutes.
At 09:50 the physician was again contacted due to "drop in patient's pulse and blood pressure". The doctor instructed to start IV bolos 200 cc and to send the patient out".
Review of nursing documentation (no time) revealed information that "vitals dropped at extreme rate" (there was no information of actual measurement of vital signs).Patient was transported to an Acute Care Hospital. Family notified at 12 noon. Family member angry and stated "he won't be coming back to your facility".
Review of physician's orders revealed a verbal order to "Administer IV bolos(200-300 cc). Monitor vitals q15 minutes".
Review of vital sign records dated 7/1/2014 at 04:00 revealed one entry of pulse 86, blood pressure 129/64 and respiration 18. There was no other documentation of vital signs for 7/1/2014.
Review of Medication Administration Record for Patient # 2 whose medication was given in error to Patient (#1) revealed the administered medications were:
Aspirin 81 milligram,
Plavix 75 mg,
Potassium Chloride 10 milliequivalent (meq.),
Lopressor 50 mg twice daily.
Lanoxin 0.125 mg, daily
TRICOR 145 mg.
Review of the incident report revealed no documentation of what medications were administered.
During a telephone interview on 9/15/2014 08:45 am with Staff (A) Licensed Vocational Nurse she stated on the day of the incident Patient (#1) was sitting outside the room of Patient (#2) and answered to that patient's name. The Nurse stated she did not check the identification band on the patient's arm.
During an interview on 9/5/2014 at 10:15 am at the facility with Staff (B) Quality Director, she stated the incident was not evaluated by the Quality department and that should have been done.

Based on record review and interview the facility failed to provide evidence there was adequate Registered Nurse supervision of patient care to ensure a patient was not given the wrong medication;
Failed to provide evidence that physician ' s orders for daily bath and shave was carried out and ;
Failed to provide documentation that an order for 15 minutes vital sign was done for a patient who's vital signs became unstable after staff gave him the wrong medication. Citing one (1) patient named in a complaint. Patient # 1
Findings:
Review of complaint narrative revealed allegations Patient # (1) was given eight (8) medication that was prescribed for another patient which resulted in unstable vital signs and he had to be transferred out for higher level of care.

There was allegations the patient was filthy during his hospital stay because facility staff did not give him baths.
Review of admission assessment notes revealed Patient # (1) was admitted to the facility for rehabilitative care after he fell and lacerated his skull. The patient had a diagnoses of Alzheimer Disease, with multiple notations that he was forgetful and confused at times.
Nursing notes dated 7/1/2014 reveal documentation that at "08:54 patient was seen in the Common area eating. The patient was given the wrong medication. At 09:25 am the patient's Physician was informed of the error and he instructed to monitor patient every 15 minutes.
At 09:50 the physician was again contacted due to "drop in patient's pulse and blood pressure". The doctor instructed to start IV bolos 200 cc and to send the patient out".
Review of nursing documentation (no time) revealed information that "vitals dropped at extreme rate" (there was no information of actual measurement of vital signs).Patient was transported to an Acute Care Hospital. Family notified at 12 noon. Family member angry and stated "he won't be coming back to your facility".
Review of physician's orders revealed a verbal order to "Administer IV bolos(200-300 cc). Monitor vitals q15 minutes".
Review of vital sign records dated 7/1/2014 at 04:00 revealed one entry of pulse 86, blood pressure 129/64 and respiration 18. There was no other documentation of vital signs for 7/1/2014.
Review of Physician admission orders dated 6/25/2014 revealed an order for "daily shave and bath" for Patient (# 1).
Review of nurses' notes revealed one notation that a shower was given on 6/27/2014; there was no other recording that Patient (#1) had a bath or was shaved.
Review of the twenty four hour nursing assessment for Patient (#1) revealed no evidence that a Registered Nurse (RN) was involved in his care for the period of 7:00 am on 6/30/2014 until after 10:05 am on 7/1/2014 when the patient was transferred from the hospital.
Review of the 24 Hour Rehab Nursing Patient Care Documentation record revealed requirement of "RN Assessment every 24 hours".
Review of Medication Administration Record for Patient # 2 whose medication was given in error to Patient (#1) revealed the administered medications were:
Aspirin 81 milligram,
Plavix 75 mg,
Potassium Chloride 10 milliequivalent (meq.),
Lopressor 50 mg twice daily.
Lanoxin 0.125 mg, daily
TRICOR 145 mg.
During a telephone interview on 9/15/2014 08:45 am with Staff (A) Licensed Vocational Nurse she stated on the day of the incident Patient (#1) was sitting outside the room of Patient (#2) and answered to that patient's name. The Nurse stated she did not check the identification band on the patient's arm.
The Surveyor asked Staff (A) what Intra Venous fluid she gave Patient (#) since the order did not specify, she said it was normal saline 0.9%.