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Based on record review and interviews, the facility failed to ensure that an unresolved patient care grievance made by a family member of 1 (Patient #2) of 3 patients was forwarded to the Patient Advocate for investigation and/or further actions for resolution. This failure resulted in the daughter requesting an early discharge for Patient #2.

Findings showed:

Review of Policy Number RTS-04, "Patient Grievance Process," revised 09/01/2024 and approved by the Governing Body, showed:
"The policy applies in all Oceans Healthcare facilities.
Purpose:
To provide an internal process that establishes guidelines for:
" Submission of a patient and/or family's grievance allegation to the facility
" Timely review and investigation of the allegation
" Provision of a response ...
Policy:
... Each facility has identified an individual to serve as the facility Patient Advocate who is responsible for the follow up and response to grievances submitted by a patient or caregiver ...
Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights ...
Procedure:
... 2. Depending on the nature of the complaint, the staff will offer resolution at the time the complaint is made, and if resolved, report the encounter to the Patient Advocate. The complaint with resolution will be logged on the 'Complaint/Grievance Log' with no additional action.
3. If no resolution is made by staff present at the time of the complaint, the Patient Advocate is notified, and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately ...

Review of the Complaint Log for October and November 2024 showed that a complaint from Patient #2, or any family member of Patient #2, had not been recorded on the log.

In an interview with Staff D on 12/12/2024, 10:03am-10:14am, she reviewed the progress notes, identified herself as the author, and stated that Patient #2's daughter expressed concerns over the inability to get fundamental medical equipment - a raised or elevated toilet seat and a walker to assist with ambulation. Staff D also said she did not pass this complaint to any other discipline.

In an interview with Staff H (Patient Advocate) on 12/12/2024, 9:30am-9:40am, she stated she did not receive any correspondence from Staff D (Director of Clinical Services) concerning a complaint or grievance made by Patient #2 or any family member of Patient #2. She also stated she should be notified of any complaint or grievance made to clinical staff members by a patient or caregiver.

Based on record review and interview, the facility failed to ensure two patients (Patient #1 and #15) were not neglected during the discharge process, as shown by the facility:

a. transporting two patients (Patient #1 & 15) from the facility to wrong nursing home/personal care home facilities during discharge, along with wrong medications and belongings;

b. failing to generate an Incident Report and perform a subsequent investigation for the occurrence, despite having knowledge of the event;

c. not following up with receiving facilities at the time of patient discharges for two patients (Patient #1 & 15) to give nurse-to-nurse reports, ensuring safe and effective continuity of care, and;

d. failure to document corrective action to prevent future occurrences.


Findings included:


Review of facility policy #QAPI-004 titled "Incident Reporting", last revised 8/1/24, showed that one of the purposes of staff writing incident reports was to document potential adverse Patient Incidents discovered. The policy's definition of Patient Incident is anything that is out of the expected norm for the patient. In addition, the policy states that any staff member who discovers or who has direct knowledge of an incident involving a patient must complete an incident report before leaving the facility at the end of the day or the end of their shift.

Review of another facility policy, #PC-18, titled "Discharge Planning: Transition Record", last revised 10/1/24, showed that the facility shall finalize the patients' post-treatment care plans with the facility that the patient is being transferred to, for the purposes of meeting their ongoing needs for care and services.

Record review of facility's Incident Report log for August, September and October of 2024 revealed there were no entries or investigations involving Patient #1 or Patient #15.

In an interview on 12/12/24 at 10:15 am, Director of Clinical Services (DCS)-Staff #D stated there was an issue with Patient #1's discharge: When he was transported via Oceans Katy's van, he apparently "switched belongings and identity" with another patient and was transported to the other patient's nursing home. The other patient, in turn, was brought to Patient #1's personal care home. Staff #D added that she did not know the name of the other patient but was told he looked similar to Patient #1. Oceans Katy then received a call from the facility where Patient #1 was brought, a nursing home where the unknown patient was supposed to be. Staff #D then stated there was no incident report done or investigation made by Oceans Katy but would have expected one to have been done for the occurrence.

In an interview on 12/12/24 at 10:30 am, Director of Nursing (DON)-Staff #B stated Patient #1 impersonated another patient while in Oceans' transport van and was brought to the other patient's nursing home. Further interview with Staff #B revealed she did not know the name of the other patient either and would have expected an Incident Report to have been generated, followed by an investigation. Staff #B also acknowledged that if an incident report was done and an investigation performed, the facility could have determined who the other patient was and attempted to ensure his safety. When questioned about any corrective actions the facility had taken to prevent future occurrences, Staff #B stated that pictures of the patients were now being given to the transport drivers, but this was not documented or placed in any facility policies.

In an interview on 12/12/24 at 11:00 am, CEO-Staff #A stated he knew about the event but did not recall who the other patient was that switched identities with Patient #1. Staff #A also stated that after learning of the event, he arranged to have the patients transported to the correct facilities. He also stated that Oceans Katy could have handled the situation better, which included performing an investigation.

Staff #A then subsequently performed a search of patients who discharged on 9/12/24 that were present in the van with Patient #1 and presumably determined, through the process of elimination, that the other person was most likely Patient #15.

In an interview on 12/12/24 at 12:40 pm, Driver-Staff #P also stated that Patient #1 and another patient switched identities and when he called out Patient #1's name just before dropping him off, the other patient responded, but Staff #P did not recall who this other patient was either. He also stated that Patient #1 was dropped off with the other patient's medications and belongings and the other patient was dropped off with Patient #1's medications and belongings. When questioned if Staff #P believed the other patient was Patient #15, he stated the name sounded very familiar and believed it was the same person.

Record review of Patient #1's medical records showed he was involuntarily admitted to the facility on 8/30/24 and discharged on 9/12/24. His final diagnoses where Dementia, Unspecified, and Schizoaffective disorder. There was no information documented about the patient being transferred to the wrong facility at discharge.

Record review of Patient #15's medical records showed he was voluntarily admitted to the facility on 8/31/24 from a nursing home and discharged on 9/12/24. His diagnoses were Dementia (assessed by his attending physician on 9/11/24 to be Major Neurocognitive disorder, vascular type) and Bipolar disorder, type II. There was no further information about the patient being transferred to the wrong facility at discharge.

Record review of Patient #1's and Patient #15's medical records revealed Nursing Progress Notes that were identical, written by RN-Staff #O, both dated 9/12/24 at 6:57 pm. The note(s) documented that the patients discharged facility on 9/12/24 at 4:45 pm with their discharge medications and transported by Oceans Katy. RN-Staff #O also documented that the nurses at the "receiving hospital" (no name of nurses or facilities listed) were called to give nurse-to-nurse reports (no times specified when the calls were made) and there was "no response" by the other facilities. There was no further information subsequently documented and no follow-up calls indicating additional attempts were made to contact the other facilities. In addition, there was no indication this lack of contact was ever communicated with other Oceans Katy staff, such as another RN or supervisor. There was no documentation of any follow-up or attempted follow-up with the other facility to ensure continuity of care for Patients #1 & 15.

During the interview on 12/12/24 at 10:35, DON-Staff #B acknowledged there should have been more of an effort by RN-#O or other nurses to follow through with contacting the receiving facility. Staff #B also stated the nurse who was supposed to give nurse-to-nurse report was currently out of the country and was not available for interview.

Based on record review and interview, the facility failed to ensure that Clinical Services staff documented in the medical record of 1 (Patient #2) of 2 patients concerns raised by family during a family therapy session. This failure resulted in the patient's daughter requesting an early discharge of Patient #2 who was actively experiencing paranoid delusions, auditory hallucinations, and visual hallucinations.

Findings showed:

Review of a Family Therapy Session Note dated 10/08/2024, 12:18pm, by Staff D (Director of Clinical Services) for Patient #2 showed:
"Therapist spoke to daughter about patient's admission and concerns. Daughter expressed several concerns about mother's admission and care including concerns for physical limitations. She shared that patient has always struggled with mental health as evidenced by verbal aggression, flucuating [sic] moods, paranoia, delusions, high anxiety and AVH [auditory and visual hallucinations]. Patient reported AVH to daughter as recently as today, of '2 men standing over her bed saying they were going to take her.' Therapist updated daughter of patient's current treatment, medication compliance and aftercare plan. Daughter requested early discharge for patient."

Review of Family Therapy Session Note dated 10/10/2024, 4:13pm, by Staff D for Patient #2 showed:
"Therapist spoke to patient and daughter about treatment progress and discharge plans ... Patient and daughter struggled to comprehend the reason for Patient's admission and continued stay. They were minimizing of her behaviors, paranoia, delusions and AVH of 'men' ... Daughter will pick up and transport patient at time of discharge."

In an interview with Staff D on 12/12/2024, 10:03am-10:14am, she reviewed the progress notes, identified herself as the author, and stated that Patient #2's daughter expressed concerns over the inability to get fundamental medical equipment - a raised or elevated toilet seat and a walker to assist with ambulation. Staff D also said that her documentation of the family session was insufficient in that she failed to document the specifics of the complaints voiced by the daughter. Staff D concluded the interview by saying that at the end of the Family Therapy session, the daughter did indeed request an early discharge of her mother from the facility.

Review of Policy Number NSG-02, "Documentation," revised 01/01/2023 and approved by the Governing Body, showed:
"This policy applies to all Oceans Healthcare facilities ...
Purpose:
... To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient.
To increase communication among the various disciplines providing care to the patient.
To provide concise and comprehensive information as a part of a legal document ..."

Review of Policy Number AS-13, "Guidelines for Timely Completion of Clinical Task/Required Documentation" revised 06/01/2023 and approved by the Governing Body, showed:
"This policy applies to all Oceans Healthcare facilities ...
Purpose:
To provide for an effective system to communicate tasks and documentation requirements. It is also a process to ensure follow up and accountability for completion of these tasks.
Policy:
The hospital ensures that patient care is documented in a complete and timely manner ...
Procedure:
... Family ... contacts ... should be documented accordingly in the medical record."

In an interview with Staff B (Director of Nursing) and Staff M (Nursing Supervisor) on 1/12/2024, 12:58-1:15pm, Staff B stated that complaints made to other disciplines by patients or family members concerning nursing care need to the communicated to a member of Nursing Services.