Pam Rehabilitation Hospital of Tulsa

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 39648 Based on review of admission paperwork, it was determined the hospital failed to provide the correct information to patients on how to contact the Oklahoma State Department of Health for the resolution of complaints and grievances. This failed practice had the potential to effect the ability of all past and current patients to make a complaint. Findings: A Reviw of “Patient Rights and Responsibilites” Page 3 of 4 section of the admissions paperwork documented the following: You may also notify: Oklahoma Department of Health 1000 NE 10th Streeet Tulsa, OK 73117 (800)522-0203 On 08/28/24 at 10:30 AM Staff A was shown the following information from the OSDH website: Complaints against non-long term care facilities may be filed electronically by email: medfaccomplaints@health.ok.gov or by calling (405) 426-8470 or by written statements using the Medical Facilites complaint form and mailed to the mailing address listed below: Oklahoma State Department of Health Medical Facilities 123 Robert S. Kerr Ave., Suite 1702 Oklahoma City, OK 73102-6406 Staff A stated, “The information given to patients to make a complaint with OSDH was not correct.””

“PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 39648 Based on record review and interview, it was determined the hospital failed to ensure a patient’s family member concerns were addressed for one (Pt #14) of 20 patients. Findings: On On 08/29/24, at 1:44 pm a record review showed a Progress Note dated 10/25/23 that showed, “The daughter is very frustrated and upset that she has had great difficulty being able to call her mothers room, being able to reach a nurse, or almost anyone at the facility. Will pass on to the charge nurse to be available to speak with her when she arrives to the facility.” A review of the hospital’s grievance policy was reviewed and read in part: “If the patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then then the complaint is a grievance.” On 08/29/24 at 1:44 PM Staff E stated, “I cannot find documentation that the issue the daughter discussed with the provider was followed up with the daughter.” On 08/30/24 at 11:09 AM Staff F stated, “If the issues were not resolved at the bedside it should have come to me. I do not have a complaint regarding this.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 39648 Based on record review and interview the hospital failed to ensure nursing staff revised the plan of care based on evaluation of the patient’s response to care relative to the planned patient outcomes for one (Pt #17) of 20 patients. Findings: Pt #17 A review of the Plan of Care initiated on admit date of 08/09/24 did not include the risk of pressure ulcers. Record review showed a diagnosis of obesity, a right rotator cuff repair prior to admission and numerous other diagnosis that would place this patient at risk of pressure ulcers. After the development of two bilateral Stage 1 heel uclers the plan of care was updated due to Actual wound, risk for pressure ulcer on 08/12/24. The need to monitor dietary intake was not added to the care plan although this patient was right hand dominant and had had a right rotator cuff repair. A review of OT initial evaluation dated 08/10/24 showed the patient required partial/moderate assistance while eating. The Intake Record had no dietary intake for 8/11/24 or 8/12/24 (patient was transferred to a hospital 8/12/24) On 08/29/24 at 2:30 PM, Staff E stated, “I cannot show documentation meal intake for the 11th or any meal refusal for August 11, 2024. The Plan of Care was updated due to the development of pressure ulcers August 12, 2024.””