Wise Medical Staffing Inc.

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to thoroughly investigate complaints. This affected one (Patient #1) but had the potential to affect all 526 patients. The census was 526. Findings include: Review of Patient (Pt) #1’s medical record revealed an admission date of 12/13/23. Diagnoses included chronic obstructive pulmonary disease (COPD), bilateral scoliosis and history of urinary tract infections. Review of the Aide plan of care effective 12/13/23 revealed the patient had a history of paralysis, poor vision, needs assistance for major activities of daily living and medication reminders. The patient was to receive 104 hours of aide services each week. The medical record contained an Incident report dated 11/01/24 in which Patient #1’s family member accused Staff A of stealing the patient’s medications while she was in the hospital from 10/25/24 through 10/30/24. Review of the complaint investigation revealed on 10/30/24, no time noted, Patient #1’s family member sent a text to the scheduler stating Staff A is being “very irresponsible with her newfound freedom away from rehab.” The family member did not want Staff A back in Patient #1’s home and stated with, “with everything on with {Patient #1’s] meds since she started, she is a huge liability for us.” Another text on 10/31/24 to the scheduler from Patient #1’s family member stated there was one diazepam (anti-anxiety medication), 91 oxycodone (narcotic medication to relieve severe pain), 32 Lyrica (medication that treats nerve pain) 25 milligram (mg) and 41 Lyrica 50 mg missing since the last time they were counted on 10/16/24 through 10/31/24. There was another string of undated texts between Staff A and Patient #1’s family member in which the family member stated she told Staff A that the police had been called, for her to get her belongings from Patient #1’s house by 9:00 PM and she was no longer allowed back at the residence. During an interview on 12/24/24 at 12:05 PM, the Administrator stated Patient #1 has multiple sclerosis, cannot move her limbs and is bed confined. She stated the aides that worked with Patient #1 would get the patient’s medications from a lock box, out of a medication planner that the patient’s family member would set up. The Administrator stated the lock box has a camera facing it and so does the patient. She stated cameras were throughout the house so the patient’s family could check on Patient #1, however, the cameras were constantly not working. She stated Patient #1 would look at the medications and verify that the medications were correct before taking them. The Administrator verified that Patient #1’s family member verbalized concerns about medications being passed wrong back in September of 2024 and that aides were to contact the family member via phone before they gave the patient her medications and document the medication given, time, and date starting 09/15/24. The aides were educated on signing out the medication and calling the family member. The Administrator verified the medications were not being counted by her staff unless the patient asked for them to count in front of her. She stated the family member was in charge of setting up and counting the medications. She stated the family member reported she had counted the medications on 10/15/24 and not again until 10/31/24 when she reported missing medication. The Administrator verified that Staff A did move in with Patient #1 sometime in October 2024 but stated once the aide moved in, Patient #1 and Staff A were educated by the agency. The Administrator verified there was documentation provided on the education. The Administrator stated they did not speak Patient #1 concerning the missing medications because the patient was sick in the hospital. However, the Administrator verified the patient was not in the hospital on 10/31/24. She was hospitalized on 11/01/24 and 11/02/24 then returned home and is a current patient. Review of the policy titled “Complaint Resolution” revealed each resident is provided information regarding patient rights and information on filing complaints in writing. The agency will document the existence of the complaint, investigate, document the complaint resolution, and take action to prevent potential violations. Complaints will be logged, tracked and trended. The designated individual responsible to resolve the complaints is the Director of Clinical Services. Corrective action will be specific and directly related to the complaint. The agency staff must immediately report misappropriation to the agency and other appropriate authorities. The patient should receive a positive response to complaints within 24 hours, if not the patient should ask to speak to the Administrator and a response will be provided within three business days. If the patient feels further investigation is needed, they may appeal to the Governing Body and a response will be received within 5 business days. At any time, the patient may file a complaint with the Ohio Department of Health. The agency maintains records of grievances/ complaints and the outcomes.”