HospitalInspections.org

Based on a review of facility policies and patient records, as well as staff interviews, the facility failed to follow its established process for prompt resolution of patient grievances.

FINDINGS WERE:

A review of patient or patient representative complaints/grievances made at the facility since August, 2013 did not include the complaint(s) made by the family of Patient #1. In an interview with Staff #6 on the morning of 12/4/13, she confirmed that the family made complaints regarding the care of Patient #1 which were not immediately addressed and/or resolved. In a telephone interview with the patient's family member on the morning of 12/4/13 at approximately 9:20 a.m., she said the family had made "repeated" complaints regarding Patient #1's care to the Director of Nursing, the Charge Nurse, and the facility Chief Executive Officer which had not been resolved.

Facility policy #LD.49 entitled Patient/Family Concerns of Grievances, stated in part, "Patients or family members may file a complaint by addressing their concerns verbally or in writing to any member of the hospital team ...
Procedure ...
2. The individual receiving the complaint will initiate the Complaint/Grievance Form and take any steps available to resolve the complaint. After documenting efforts to resolve the complaint, the Complaint/Grievance Form should immediately be given to the appropriate Department Head..."

The above findings were confirmed in an interview with the facility Director of Nursing and other administrative staff the afternoon of 12/4/13 in the facility conference room.

Based on a review of facility policies and patient records, as well as staff interviews, the facility failed to ensure a completed general informed consent for treatment, or "Hospital Consent," was completed for each patient receiving treatment at the facility.

FINDINGS WERE:

A review of patient medical records revealed a general hospital informed consent for treatment signed by Patient #1 on 8/15/13. The date of his admission to the facility was 8/9/13. The medical record of Patient #1 included documentation of family at the bedside.

In addition, the general hospital informed consent for treatment forms for Patients #2 and #3 revealed signatures dated one day post-admission. The general hospital informed consent form for Patient #9 was signed upon admission, but was not witnessed, and thus was invalid.

Facility policy #RI.1, entitled Admissions Forms, effective date 1/01/09, stated in part, "Policy:
The assigned Business Office personnel will present, explain and obtain the signature of the patient or responsible party on all required Admission Forms...
Purpose:
To ensure that all necessary consent, notification and rights are presented to the patient upon admission to the Facility.
Procedure:
1. All required forms are reviewed and explained to the patient and signatures are obtained. Required forms are listed below:
a. Consent for Treatment Form...
b. "Advance Directive" information
c. "Hospital Consent" Form..."

A review of the facility Specialty Hospital Medical Staff Rules & Regulations revealed the following:
"C. General Conduct of Care...
2. A general consent form, signed by, or on behalf, of every patient admitted to the Hospital, shall be obtained at the time of admission. The admitting clerk or nurse, as appropriate, shall notify the attending practitioner whenever such consent has not been obtained and shall make an entry in the medical record explaining the reason the consent was not obtainable..."

The above findings were confirmed in an interview with the facility Director of Nursing and other administrative staff the afternoon of 12/4/13 in the facility conference room.

Based on a review of facility policies and patient records, as well as staff interviews, the facility failed to ensure required physician orders were included in the patient record which provided the information necessary to monitor the patient's condition.

FINDINGS WERE:

A review of patient medical records revealed no discharge or transfer orders in 1 of 3 closed records [Patient #10]. The medical record of Patient #10 revealed the last physician order was dated on 10/18/13. The patient had been transferred to another facility per other documentation in the record. No physician order was included regarding the patient's discharge or transfer from the facility.

A review of the facility Specialty Hospital Medical Staff Rules & Regulations revealed the following:
"A. Admission and Discharge of Patients ...
7. Patients shall be discharged from the Hospital on the written order of the patient's attending physician ..."

The above findings were confirmed in an interview with the facility Director of Nursing and other administrative staff the afternoon of 12/4/13 in the facility conference room.

Based on a review of facility policies and patient records, as well as staff interviews, the facility failed to ensure a discharge summary with outcome of hospitalization, disposition of care and provision for follow-up care was available at all or was completed in a timely manner in 3 of 3 closed patient medical records reviewed.

FINDINGS WERE:

A review of patient medical records included 3 closed patient charts of discharged patients. In 2 of 3 records [Patients #5 and #10], no discharge summary was available. Patient #5 had been discharged on 9/26/13. Physician Orders for Patient #10 ended on 10/18/13. The lack of Discharge Summaries had not been noticed by the facility.

In the chart of Patient #1, the Discharge Summary showed a dictation date of 10/9/13. Patient #1 was discharged from the facility on 8/16/13. A facility Nurse Practitioner signed the discharge summary for Patient #1 on 10/29/13 and the Medical Director signed it on 10/31/13.

A review of the facility Specialty Hospital Medical Staff Rules & Regulations revealed the following:
"A. Admission and Discharge of Patients ...
7. Patients shall be discharged from the Hospital on the written order of the patient's attending physician ...
B. Medical Records ...
11. A discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized over forty-eight (48) hours. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible practitioner...
13. The attending practitioner shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnosis and discharge summary...
14. If the discharge summary is not completed within fifteen (15) days of the discharge, the medical record will be deemed delinquent..."

The above findings were confirmed in an interview with the facility Director of Nursing and other administrative staff the afternoon of 12/4/13 in the facility conference room.

Based on a review of facility policies and patient records, as well as staff interviews, the facility failed to provide organized rehabilitation services as designated by facility policy and acceptable standards of practice.

FINDINGS WERE:

A review of open patient medical records revealed that in 4 of 7 records [Patients #2, 6, 8 and 9], with admission dates ranging from 11/6/13 to 11/30/13, despite physician orders for an occupational therapy evaluation and treatment, the evaluation had not been completed. In 1 of 7 open patient charts [Patient #3], the occupational therapy evaluation had been completed, but was completed four days after the physician had ordered the evaluation. Thus the evaluation was not completed within the time parameters set forth by facility policy.

Additionally, despite a physician order dated on the patient admission date of 11/6/13 for Patient #2 for a speech therapy evaluation, there was no evidence available in the medical record that the speech therapy evaluation had been completed.

In an interview with a facility occupational therapist on the afternoon of 12/4/13 in the rehabilitation therapy office, he admitted the occupational therapy evaluations had yet not been completed for Patients #2, 6, 8 and 9, despite physician orders for them.

In an interview with the facility Director of Nursing on the afternoon of 12/4/13 in the facility conference room, she stated, " I just very recently realized some of these rehabilitation services were not in the chart and were an issue."

Rehabilitation Policy #206, entitled Evaluation - Plan of Care (POC), last revised 01/01/11, stated in part:
"POLICY
The evaluating therapist will complete an Evaluation - plan of Care (POC) form during or upon completion of the evaluation process for each new patient on caseload.

The Evaluation - Plan of Care (POC) form is to be initiated within 2 working days of the date of the physician ' s order. If the form cannot be completed on the day of the evaluation, provide as much information as possible; any additional information should be documented in a Narrative Treatment Note on the next treatment day also noting the reason the POC was not completed on the day of evaluation..."

The above findings were confirmed in an interview with the facility Director of Nursing and other administrative staff the afternoon of 12/4/13 in the facility conference room.