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Based on policy and procedure review, medical record review, internal document review and staff interview, the hospital staff failed to identify and respond in writing to a grievance for 1 of 1 complaint reviewed (Patient #3).

The findings included:

Review on 05/22/2019 of a policy titled "Patient Complaint/Grievance Resolution Process" last revised 03/2019 revealed "...Patient Complaint - a patient issue that can be resolved promptly and on the spot by staff present...If a verbal 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 the complaint is a grievance for the purpose of this policy...Patient Grievance - a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's authorized representative...regarding the patient's care, abuse or neglect while in the hospital or after discharge, when a patient complaint cannot be resolved promptly by the staff present at the time of the complaint..."

Review of emergency room (ER) visits for Patient #3 revealed she was brought to the ER from her assisted living facility (ALF) by EMS (Emergency Medical Services) on 02/14/2019 and discharged back to the ALF with a urinary tract infection. Review of the closed record revealed no documentation about Patient #3's pressure ulcer. Review revealed Patient #3 returned to the ER on 03/19/2019 for a rash and "bedsore check." Review revealed no documentation about Patient #3's pressure ulcer.

Closed medical record review of Patient #3 on 05/21-22/2019 revealed she was admitted on 03/22/2019 at 2330 for an infected sacral decubitus. Review revealed Patient #3 had a history of dementia and was non-ambulatory and non-verbal. Review revealed general surgery was consulted for Patient #3's pressure ulcer on 03/23/2019. Review of the general surgery note revealed "...Patient is unable to provide any information...in the patient's chart she has had a continued breakdown of skin over last several weeks...patient does not have a decubitus ulcer requiring debridement eschar in the area of the sacrum...does not appear to be infected..." Review revealed Patient #3 was started on IV (intravenous) Zosyn (antibiotic) and IV Vancomycin (antibiotic) to treat the infection. Review of the physician orders revealed an order started on 03/22/2019 for IV Vancomycin every 12 hours and IV Zosyn every 6 hours. Review revealed on 03/24/2019 Vancomycin was scheduled for 1400 and was given at 1503 (1 hour and 3 minutes after the scheduled time). Review revealed on 03/24/2019 Zosyn was scheduled for 1500 and given at 1738 (2 hours and 38 minutes after the scheduled time). Review of the physician progress note on 03/24/2019 revealed Patient #3's family wanted a transfer to a facility with a wound care specialist. Review revealed MD #2 (Medical Doctor) attempted to transfer Patient #3, but she was not accepted at the two family requested hospitals. Review revealed Patient #3 would stay in the hospital and the hospitalist and general surgeon would manage her wound until the family decided on the disposition. Review of a nursing note on 03/26/2019 at 0624 revealed "...Pt's (patient's) (family member name), called early this AM at 0225 and was asking if pt had an enema yesterday and notified her that she had an order on Sunday and was done. Family said that they were here the whole day of Sunday and no enema was given to pt. Informed family that writer was here that night and that was reported to me that she did have an enema with minimal results as per report. Family insisted that writer call MD to get an order for an enema...Writer told family that I would relay it to MD. Family also was upset that pt only had 25% of dinner yesterday. She said that pt. can't feed herself and will eat if she is fed and that 25% is not acceptable and that's negligence. She said that she will be here first thing in the morning...and stated that she will take legal action for negligence..." Review of the physician progress note on 03/27/2019 at 1024 revealed "...Discussed with family yesterday...and they expressed their dissatisfaction with Nursing care and the Case Mgr. Questions answered..." Review revealed Patient #3 was discharged on 04/15/2019 to home with hospice.

Review on 05/23/2019 of an email from the House Supervisor to the Director of Quality on 03/24/2019 revealed Patient #3's family complained that Patient #3's pressure ulcer was not assessed on her two previous visits to the ER, 02/14/2019 and 03/19/2019. Review revealed the email was sent to the ER Director for followup. Review of handwritten notes on the email revealed on 03/25/2019 at 0900 the ER Director called Patient #3's family and was told Patient #3 was an inpatient at the hospital. Review revealed the Nurse Manager of the floor Patient #3 was on followed up on the complaints on 03/25/2019 at 1230 and the family had no further questions. Review revealed on 03/26/2019 at 0900 the Nurse Manager of the floor followed up with the family again and they had no further questions.

Interview on 05/22/2019 at 1500 with the House Supervisor revealed she recalled Patient #3's family complaining about two different concerns during her admission. Patient #3's family complained that during Patient #3's two previous ER visits her pressure ulcer had not been assessed. Interview revealed the House Supervisor reviewed the chart and did not see an assessment on the 02/14/2019 visit and could not remember if there was one on the 03/19/2019 visit. At the end of the conversation with Patient #3's family she told them she would forward the complaints because "obviously it wasn't going to be solved that day, she (Patient #3) already had pressure ulcers." Interview revealed she emailed the concern to the Director of Quality. Interview revealed the second complaint was brought to her by MD #2 who came to the House Supervisor and told her Patient #3's family complained about an IV antibiotic being late and the family started the infusion themselves. The House Supervisor went to RN #2 to ask her about it and RN #2 stated it did not happen. Interview revealed the House Supervisor did not talk to Patient #3's family about this concern and did not tell anyone else in administration.

Interview on 05/22/2019 at 1410 with MD #2 revealed he discussed the concerns Patient #3's family had with the House Supervisor. Patient #3's family was concerned Patient #3's pressure ulcer had not been assessed during previous ER visits and that the nurse had not given IV antibiotics on time, so Patient #3's family started the infusion themselves. Interview revealed Patient #3 had a chronic pressure ulcer because she was bedbound, and would have had the pressure ulcer on previous visits. Interview confirmed there was no documentation during the previous two ER visits about Patient #3's pressure ulcer.

Interview on 05/22/2019 at 1515 with the Director of the ER revealed she received an email on 03/25/2019 about Patient #3's family complaining of Patient #3's pressure ulcer not being assessed for two ER visits. Interview revealed she reviewed Patient #3's chart and when she called Patient #3's family she found out Patient #3 was an inpatient at the hospital. The Director of th ER notified the Director of Quality, and the Nurse Manager on the floor Patient #3 was on, went to talk with Patient #3's family. Interview revealed there was no documentation about Patient #3's pressure ulcer on the 02/14/2019 or 03/19/2019 ER visit.

Interview on 05/22/2019 at 1700 with the Director of Quality revealed Patient #3 was not on the grievance log. Interview revealed normally if there was a concern the Director of Quality asked the Nurse Manager of the unit to follow up with the patient or family. If the complaint was resolved then the Nurse Manager of the unit was told to ask if the patient or family wanted a more formal investigation or wanted to speak with the Director of Quality. Interview revealed if the family or patient wanted a more formal investigation or to speak with the Director of Quality it was considered a grievance. If the family or patient did not want a more formal investigation nor wanted to speak with the Director of Quality then the complaint was resolved and it was not considered a grievance. Interview revealed the Director of Quality received an email from the House Supervisor about Patient #3's family complaints. Interview revealed she forwarded this to the Director of the ER for follow up because it was about Patient #3's ER visits. The Director of the ER called Patient #3's family and found out Patient #3 was an inpatient at the hospital and told the Director of Quality. Interview revealed the Director of Quality called the Nurse Manager of the unit Patient #3 was on to follow up on Patient #3's family's complaints. Interview revealed the Director of Quality talked with the Nurse Manager of the unit twice and was told the family had no further questions. The Director of Quality considered the complaint to be resolved. Interview revealed if Patient #3 had not been an inpatient it would have been a grievance. Interview revealed the Director of Quality did not know about Patient #3's family's concerns that they hung an IV antibiotic because it was late. Interview revealed the Director of Quality would want to be notified of that. Interview revealed the Director of Quality had never spoken to Patient #3's family. Interview revealed the Nurse Manager of the unit Patient #3 was on, no longer worked at the facility and the Director of Quality did not have any paperwork about the discussion the Nurse Manager of the unit had with Patient #3's family.

Based on policy and procedure review, medical record review, and physician and staff interviews, facility staff failed to assess a patients pain per policy for 1 of 8 inpatient medical records reviewed (Patient #3) and failed to assess a patients pressure ulcer in the emergency room (ER) for 1 of 1 patients with a pressure ulcer (Patient #3).

The findings included:

1. Review on 05/21/2019 of a policy titled "Pain Management" last revised 04/2018 revealed "...Every patient shall be assessed for pain and shall have their pain treated and managed on an ongoing basis wherever patient care is rendered...Every patient shall be evaluated for the effectiveness of interventions performed...Ongoing pain assessments shall be completed and documented each shift and as needed. The following criteria will be assessed and documented. a. Presence of pain b. Intensity of the pain, using a 0 to 10 pain scale or other scale that is appropriate for the patient. c. Location of the pain...Thirty to sixty minutes after pain relieving interventions the patient's pain shall be reassessed to evaluate effectiveness using one of the pain scales or objective findings..."

Closed medical record review of Patient #3 on 05/21-22/2019 revealed an 81 year old female admitted on 03/22/2019 at 2330 for an infected sacral decubitus. Review revealed Patient #3 had a history of dementia and was non-ambulatory and non-verbal. Review of the physician orders revealed Patient #3 had morphine and Tylenol ordered for pain management. Review revealed Patient #3 was administered 650mg of Tylenol on 03/23/2019 at 1427 with a note in the MAR (Medication Administration Record) that stated "pain." Review failed to reveal a pain level documented for the initial pain assessment and a reassessment within 30 to 60 minutes of the Tylenol administration. Review of pain assessments during Patient #3's admission revealed pain assessments were not documented once per shift on 03/24/2019, 03/26/2019, 03/28/2019, 03/29/2019, 03/31/2019, 04/01/2019, 04/02/2019, 04/04/2019, 04/05/2019, 04/10/2019, and 04/12/2019. Review revealed no pain assessments were documented on 03/30/2019, 04/08/2019, 04/09/2019, and 04/15/2019. Review revealed Patient #3 was discharged on 04/15/2019 to home with home hospice.

Interview on 05/22/2019 at 1105 with RN #2 (Registered Nurse) revealed she took care of Patient #3 on 03/24/2019. Interview revealed RN #2 did pain assessments every time she went into the room. Interview revealed pain assessments were documented on the pain assessment flowsheet. Interview revealed she was not sure why pain assessments were not documented on her shift on 03/24/2019.

Interview on 05/22/2019 at 1410 with MD #2 (Medical Doctor) revealed Patient #3 was admitted due to her pressure ulcer and excoriation in her groin. Interview revealed Patient #3 had dementia and was non-verbal. Interview revealed initially MD #2 ordered Tylenol around the clock for Patient #3's pain management. Interview revealed Patient #3's family wanted a stronger pain medication and morphine IV was ordered around the clock. Interview revealed Patient #3's groin was raw and excoriated and would be painful.

2. Review on 05/21/2019 of a policy titled "Patient Assessment" last revised 06/2017 revealed "...Patients will have problem focused assessment upon arrival with reassessments based on patient condition, procedures, medications and treatment..."

Closed medical record review of Patient #3 on 05/21-22/2019 revealed an 81 year old female who arrived to the emergency department via EMS from an assisted living facility (ALF) on 03/19/2019 at 1114. Review revealed Patient #3 had a history of dementia and was non-verbal and non-ambulatory. Review of the "Presenting complaint" revealed "EMS (Emergency Medical Services) states: arrives from (ALF). Facility reports washing with Irish Spring yesterday, which is normal soap used, rash to face, vaginal area, scalp after. Also request to have 'bed sore check out' EMS reports areas look like thermal burns. Hx (history) of dementia..." Review of the nursing assessment revealed "...Derm:(skin) redness and peeling noted to forehead. Redness and scratch marks noted to abdomen area..." Review of the "Adult Tissue Integrity Screening" revealed four questions which stated "Is the patient bed or wheelchair bound or unable to reposition themselves? (not answered) Is the patient incontinent of urine or stool? No Does the patient have existing pressure ulcers, history of pressure ulcers? No Is the patient wearing any devices, braces, or orthotics that may contribute to skin breakdown? No..." Review failed to reveal the nursing staff assessed Patient #3's pressure ulcer or answered the Adult Tissue Integrity questions accurately. Review of the physician note revealed "...This 81-year-old female comes to the ER (emergency room) today due to reaction to some unknown chemical at (sic) occurred while she was taking a bath. Patient...unable to describe what took place...Skin: rash a moderate rash is noted, on the abdomen, Rash is on the forehead into the scalp as well as area left lower quadrant..." Review revealed Patient #3 was given 125mg of Solu-Medrol (steroid) IM (intramuscular). Review of the" Medical Decision Making" revealed "Patient given 125 milligram Solu-Medrol IM. After observation. Patient has rested (sic) began to subside. Patient will be placed on prednisone daily for next 5 days. Patient is to follow up with primary care doctor next 2-3 day to evaluate for treatment. This was noted to be related to EMS for transportation back to the nursing home. Patient discharged back to nursing home good condition. Patient is return to ER symptoms worsen..." Review failed to reveal the ER physician, the triage nurse, or the primary nurse, assessed Patient #3's pressure ulcer.

Interview on 05/22/2019 at 1245 with RN #3 revealed Patient #3 was in a hallway bed in the ER. Interview revealed no nurse was assigned to Patient #3, but RN #3 saw she had an IM Solu-Medrol ordered and administered it. Interview revealed RN #3 recalled Patient #3 had a rash on her face and abdomen and put in a nursing assessment. Interview revealed RN #3 did not assess Patient #3's pressure ulcer.

Interview on 05/22/2019 at 1350 with RN #4 revealed she took report from EMS for Patient #3. Interview revealed EMS told RN #4 about her pressure ulcer and rash. Interview revealed Patient #3 was in a hallway bed and RN #4 did not assess her pressure ulcer.

Interview on 05/22/2019 at 1300 with MD #1 revealed he "vividly" remembered Patient 3's rash. Interview revealed Patient #3's rash looked like an allergic reaction. Interview revealed MD #1 assessed Patient #3's pressure ulcer and saw that the dressing was clean, and the pressure ulcer edges were granulated. Interview revealed there was no signs of infection. Interview confirmed MD #1 did not document the pressure ulcer assessment.

Interview on 05/23/2019 at 1145 with the Director of the ER revealed a more focused assessment was done on patients in the ER related to their presenting complaint. Interview revealed she expected the nursing staff to assess Patient #3's pressure ulcer since that was part of her presenting complaints. Interview confirmed there was no documentation about Patient #3's pressure ulcer.

Based on policy and procedure review, medical record review, and staff interviews, nursing staff failed to administer intravenous (IV) antibiotic medication on time per policy for 1 of 1 patient with IV antibiotics (Patient #3).

The findings included:

Review on 05/21/2019 of a policy titled "Medication Administration" last revised 08/2015 revealed "...Administer medications within 30 minutes before or after the scheduled time of administration...Documentation 1. Normal operations A. All medications are documented in EHR (electronic health record) on the eMAR (electronic medication administration record)..."

Closed medical record review on 05/21-22/2019 for Patient #3 revealed an 81 year old female admitted on 03/22/2019 at 2330 for an infected sacral decubitus (pressure ulcer). Review revealed Patient #3 was started on IV Zosyn (antibiotic) and IV Vancomycin (antibiotic) to treat the infection. Review of the physician orders revealed an order for IV Vancomycin every 12 hours and IV Zosyn every 6 hours. Review of the MAR revealed on 03/23/2019 Zosyn was scheduled for 0900 and given at 1027 (1 hour and 27 minutes after the scheduled time). Review revealed the next dose was scheduled for 1500 and given at 1719 (2 hours and 19 minutes after the scheduled time). Review revealed on 03/24/2019 Zosyn was scheduled for 1500 and given at 1738 (2 hours and 38 minutes after the scheduled time). Review revealed on 03/24/2019 Vancomycin was scheduled for 1400 and given at 1503 (1 hour and 3 minutes after the scheduled time). Review revealed on 03/25/2019 Zosyn was scheduled for 1500 and given at 1635 (1 hour and 35 minutes after the scheduled time). Review revealed on 03/28/2019 Zosyn was scheduled for 0900 and given at 1022 (1 hour and 22 minutes after the scheduled time). Review revealed on 03/28/2019 Zosyn was scheduled for 2100 and given at 2220 (1 hour and 20 minutes after the scheduled time). Review revealed on 03/30/2019 Zosyn was scheduled for 0900 and given at 1108 (2 hours and 8 minutes after the scheduled time). Review revealed on 03/30/2019 Vancomycin was scheduled for 0600 and given at 0712 (1 hour and 12 minutes after the scheduled time). Review revealed no nursing notes about why the IV antibiotic was late or if the physician or pharmacist was notified. Review revealed Patient #3 was discharged on 04/15/2019 to home with home hospice.

Interview on 05/23/2019 at 1055 with RN #1 (Registered Nurse) revealed she took care of Patient #3. Interview revealed nursing had 30 minutes before and after the scheduled time of a medication to administer it. Interview revealed if medication was going to be late then the nurse should notify the physician, reschedule it, and discuss with pharmacy. Interview revealed there should be a note written about why the medication was late.

Interview on 05/22/2019 at 1105 with RN #2 revealed she took care of Patient #3 on 03/24/2019. Interview revealed medication should be given within 30 minutes before or after the scheduled time. Interview revealed if RN #2 was not able to give a medication within the timeframe she would put a comment in the MAR about why it was late. Interview revealed she did not know why the Zosyn and Vancomycin was given late on 03/24/2019.

Interview on 05/23/2019 at 1450 with the Manager of Clinical Informatics revealed when a timed medication was more than 30 minutes late, the physician should be notified, and a note should be written about why the medication was late and if pharmacy was contacted. Interview revealed there should be "significant charting" about why a medication was more than two hours late.

Based on policy and procedure review, medical record review and staff interview, nursing staff failed to check vital signs according to policy for one of two patients who received a blood transfusion. (Patient #10)

The findings included:

Review of policy titled "Transfusions of Blood and Blood Components, 14-1g-82", last revised 02/2019, revealed "...Vital signs....must be obtained and recorded....before initiation of the transfusion, 15 minutes after the transfusion started, every hours during the transfusion and after the transfusion completion. ..."

Medical record review, on 05/23/2019, revealed Patient #10 arrived to the hospital on 05/20/2019 at 1428 with diarrhea, weakness, liver disease and acute anemia. Record review revealed an order for a blood transfusion. Review of Transfusion and Vital Signs Data revealed the first unit of red blood cells started at 1932. Vital signs at 1932 were recorded at Temperature (T) 37, Pulse (P) 60, Respirations (R) 18 and Blood Pressure (BP) 167/84. Record review failed to reveal any 15 minute vital signs taken. The transfusion was noted to end at 2100. Vital signs at 2101 (1 hour 29 minutes after the blood was hung) were T 37.0, P 59, R 18 and BP 145/85. Review of Transfusion Data revealed a second unit of blood was started at 2109 and vital signs at that time were T 37.0, P 69, R 18, and BP 141/83. Review revealed the next vital signs were taken at 2219, the time the unit of blood ended (1 hour 10 minutes later). Review of Transfusion and Vital Signs data failed to reveal vital signs per policy.

Request for interview revealed the RN (Registered Nurse) who administered the blood was not available for interview.

Interview with the Director of the Emergency Room, on 05/23/2019 at 1550, revealed vital signs should be done 15 minutes after a blood transfusion is started, that not doing so could give patients more problems. Interview revealed there was no evidence vital signs were completed according to policy.

NC00150208