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Based on a complaint investigation ACTS Intake PR 00000548, review of administrative documents accompanied by the Director of Institutional Programs (employee #14) and the Director of Nursing (employee # 11) performed on 03/09/16 at 1:00 pm, it was determine that the facility failed to take action on patient's behalf to communicate the investigative process after a grievance was placed.

Findings include:

1. During RR#1 (complaint case) performed on 03/08/16 at 10:00 am it was found that patient develop edema and ecchymosis on her left arm during treatment of hemodialysis received on 02/20/16. Patient's daughter sent a written grievance to the Quality Program related to this incident. The report of the grievance was performed on a time frame of 5 days as established on step 5 on the facility's protocol for Grievances Management.

However, it was found on the Incidents Risk Management System from 03/03/16 a written note establishing that the Acute Hemodialysis Nurse (employee #12) has to coordinate a meeting with patient's family members and the nephrologists.

a. During survey process on 03/09/16 at 1:00 pm it was found that in a period of 6 days, the Customer Service Representative or any other member of the Quality Program failed to coordinate this meeting with patient's family members to discuss the results of the grievance. A written evidence was given to the surveyors on 03/09/16 at 3:00 pm where the Institutional Programs Coordinator has called patient's daughter notifying that the meeting will be perform on February 10, 2016 at 10:00 a.m. Nevertheless, patient's daughter declined this date because family members including her could not assist at that hour. Patient's daughter desire is to have a meeting after 3:00 pm but she decided to call later the Internal Medicine physician.
No evidence was found of major efforts made by the Institutional Programs Coordinator to coordinate the meeting as patient's daughter request.

Based on a complaint investigation ACTS Intake PR00000548, record review (RR) performed on 03/08 and 03/09/16 from 9:00 am to 5:00 pm accompanied by the Medicine Department Clinical Manager (employee #1) it was found that the facility failed to ensure that the clinical record has complete documentation related to skin care interventions and patients response according to the treatment provided, as seen on 2 out of 8 records review, (RR#1 and #4).

Findings include:

1. During RR#1 (complaint case) performed on 03/08/16 at 10:00 am it was found that the 82 years old female patient arrived at the hospital ' s emergency room on 02/19/16 due to weakness and vomiting episodes. After been treated at the emergency room with intravenous (IV) fluids, medications for vomiting control and blood samples for different studies, the case was transferred to the Internal Medicine physician who has privileges to establish admission's orders. The initial diagnoses established at the emergency room were: Acute Kidney Insufficiency, Anemia and Hyponatremia. The admission ' s order to the hospital was on 02/20/16 at 3:57 am,
and a consult for Nephrologist was placed in this order. On 02/20/16 at 12:25 pm the Nephrologist placed the following orders: Type and Cross for 2 PRBC ' s to be transfuse, hemodialysis today, tomorrow then continue three times daily. Time: 3hours, Left arm fistula, BFR 300-350 ml/hr, DFR 800 ml/hr, no heparin, transfuse 2 PRBC ' s in dialysis today and Ultrafiltration 1 kg.

According to nurse's notes from the Acute hemodialysis unit on 02/20/2016, the hemodialysis began at 1:40 pm and 3 hours later finished at 4:40 pm. During the hemodialysis treatment, the needle at her left arm fistula caused an infiltration.

During interview performed 03/08/16 at 1:45 pm to the Acute Hemodialysis Registered Nurse (RN, employee #4), he stated: " (During the hemodialysis treatment), the blood transfusion started and when patient waked up, she began to move her arms. When the fistula was evaluated the vein was infiltrated. I removed the needle and canalized again in other area of the same arm and the transfusion was completed. At the end of the dialysis treatment, the patient was returned to her room. I talked with patient ' s daughter and nursing staff to apply cold compresses and raise her left arm."

On 02/27/16 the nephrologists ordered at 1:00 pm provide local care to the catheter area. On 02/27/16 the nurse signed the referral to the Skin Care Program but failed to indicate the reason for the referral, which has blank spaces. No evidence was found to determine that Skin Nurse Specialist (employee #17) has performed an initial evaluation, discussed his/her observations and recommended treatment with the head physician, nephrologists or nursing staff.

According to the facility ' s policies and procedures review performed on 03/08/16 at 1:00 pm related to Venipuncture Control (Control de Venopuntura), establishes the following: Infiltration documentation on nursing progress notes, observe affected area to detect pain or hardening, among others interventions. However, the hemodialysis flow sheet form from 02/20/16 and documented by employee #4 lacks of description of the infiltration over the arterovenous fistula and its surroundings. The RN #4 failed to describe skin condition, the extension of the infiltration and there is no evidence that he notified the head physician.

2. RR #4 performed on 03/09/16 at 2:00 pm, is a 47 years old female who was admitted on 03/06/16 with a diagnosis of Cellulitis on her left leg and receiving hemodialysis. During observational tour performed on 03/08/16 at 11:00 am it was observed that patient has red skin and a small lesion on the lateral side of her left leg. Patient referred that she has develop a lesion at home and during record review performed on 03/08/16 at 11:00 am it was found the following:

On the Medical Surgical Nursing Assessment Form, the nurse that worked with the admission process on 03/06/16 at 11:45 PM, identified on the Skin Section that skin is normal and on the anatomic figure she identified on the left leg that patient has an ulcer. There is no correlation between the provided information because the skin turgor is affected and is not normal.

On the admission ' s progress note from 03/06/16 at 11:45 PM, the nurse documented that she referred the patient to the Skin Care Program. On 03/09/16, during survey process, no evidence was found that the Skin Care Program received the referral and the patient did not know that a skin specialist nurse was going to evaluate her leg.

According to policies and procedures named Skin Prevention and Management Guidelines (Guias para la Prevencion y Manejo de Piel) reviewed on 03/08/16 at 1:00 pm, establishes on step #4 the following: "Every patient that shows ulcers from stage I, lesions, wounds and/or burns will be documented on the Skin Care Documentation form. However, the nursing staff failed to document the Skin Care Documentation form, leaving that duty to Employee #17.

The surveyor requested on 03/09/16 at 12:00 noon, an initial evaluation to be performed by the skin nurse specialist to determine the kind of lesion that patient has on her left leg. The Coordinator of the Skin Care Program (employee #17) performed the evaluation on patient ' s left leg establishing that there is a lesion not an ulcer and provided care with Alginate due to minimum exudates over the lesion.

During record review performed on 03/09/16 at 2:00 pm it was observed that the nursing staff from the Medical Surgical Unit where the patient is admitted, failed to write on the daily reassessment form the characteristics that the lesion has, who is providing care and patients response to the treatment provided.