HospitalInspections.org

Based on review of hospital documents, surveyor observations and interviews with staff and patients, the hospital failed to ensure patients/patients' representatives are informed whom to contact to file a grievance, how to file a grievance with the State agency and that all grievances/complaints not resolved at the time of the complaint by staff present are included in the hospital's grievance process.

Findings:

1. The address included in the hospital's grievance policy did not include how to access the State agency to file a complaint. The policy did not have the correct address and telephone numbers as required. The appropriate address and telephone numbers are:
Oklahoma State Department of HealthMedical Facilities Service - Complaints1000 NE 10th StreetOklahoma City, OK 73117-1299Telephone: 405-271-6576Fax: 405-271-1308Home Health Hotline: 1-800-234-7258Email: medicalfacilities@health.ok.gov
2. Two of ten complaints/grievances, one concerning patient # 1 and one on the grievance log, reviewed during the investigation were not included in the hospital's grievance process. Patient #1's grievance, which was received by both the Department and the hospital, was not included on the grievance log. This grievance was not included on the grievance log due to possible litagation according to hospital staff A.

The second grievance which was entered into the system by staff was not included in the grievance process because it was not considered a grievance by Staff A because the patient themselves did not enter the complaint/grievance. The second grievance concerned a complaint about a physician and patient care. The patient ended up leaving AMA ( against medical advice).

3. Two of two current patients and three of three hospital staff were interviewed by a surveyor on 08/20/10 between 11:00 am and 11:55 am. They were asked if they had been informed of their rights and had received the hospital's patient rights handout. The patients said they had not been given a handout about patient rights and the staff did not know about a patient rights handout. They were also asked if they knew how and to whom to file a grievance/complaint. The patients were not sure on how and to whom to file a grievance/complaint.

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Four of nine grievances reviewed did not contain a written response to the complainant containing the required elements. These four grievances were marked resolved on the grievance log, but there was no written response to the complainant. Hospital Staff A stated on 08/20/10 in the afternoon that the hospital believed the grievances/complaints were resolved before the patient/complainant had been dismissed from the hospital. Staff A also stated that since they had been resolved during the patient's hospital stay they did not require a written response even though they did not meet the requirement that the complaint is resolved at the time of the complaint by staff present. These complaints required an investigation and were not resolved at the time of the complaint by staff present.

Based on review of policies and procedures and medical records and interviews, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In one of two (Patient #1) patient records reviewed of patients with identified skin problems, the nurse did not follow the hospital's policy to identify and provide preventive skin care and the supervising nursing staff did not supervise to ensure policies were followed and nursing assessments were checked for accuracy and completeness of documentation.

Findings:

The hospital's policy for skin assessment, entitled SOS (Save Our Skin) Policy #PCM-5593, stipulated that for patients whose Braden Scale assessment was equal to or less than 18, the SOS program would be instituted.

1. Patient #1's Braden Scale on admission, 05/17/2010, was 18. Patient #1's Braden Scale for 05/18/2010 remained at 18. According to interviews on the morning of 08/20/2010 with Staff B, C, I, J, K and L, the SOS program was not completely put into place for Patient #1 until 05/19/2010, when the patient's Braden Scale was 15. Staff did not follow the hospital's policy to provide preventive skin care for Patient #1.

Staff B, C, I, J, K and L stated in the interview on 08/20/2010, that "some staff" thought the SOS program did not take effect unless the patient's Braden Scale was less than 18. The supervising nurse did not supervise nursing staff's assessments and patient care to ensure the hospital's policies and procedures were followed and ensure preventive skin care was implemented when indicated.

2. Nursing assessment/reassessment notes for Patient #1 for 05/19/2010 at 0800, 05/20/2010 at 0800 and 2100 and 05/21/2010 at 0800 documented staging of the patient's skin disruptions. On 08/20/2010 at 1115, Staff B and C told the surveyors wound/skin disruptions should only be staged by the wound care specialist, physicians/practitioners, and physical therapists. They stated nursing staff were only to describe the skin disruptions.

3. Nursing assessment/reassessment notes for Patient #1 for 05/19/2010 at 0800, 05/20/2010 at 2100 and 05/21/2010 at 0800 inaccurately staged the skin disruption on the patient's elbow as a Stage IV. The wound care specialist documented on 05/20/2010 at 1245, "Numerous skin issues. Shearing wounds to right heel resulting in Bulla approximately 3 cm. round. Shearing to buttocks bilaterally with partial thickness tissue loss. Stage I ulcer to left medial heal - no broken skin - measures approximately 0.5 cm. round and an open wound to the right elbow measures approximately 0.3 cm. round with 0.2 cm. undermining circumferentially - no odor, scant serious - sero purulent drainage."

4. Staff B stated on the morning of 08/20/2010 that the hospital did not have a policy/procedure for how patient repositioning/turning every two hours would be assured. She stated each unit decided how they would keep track of the turning. Documentation on Patient #1 record the patient was supine from admission on 05/17/2010 at 0815 until 1942 when the patient was turned to the right side. According to the medical record, Patient #1 was repositioned to supine position at 2000. Most of the nursing positioning documentation recorded the patient was supine. Interview with Staff B, C, I, J, K and L on the morning of 08/20/2010, they stated the patient's condition would not tolerate the patient being completely turned to her sides. However, they stated while Patient #1 remained supine, she was tilted/propped up with pillows to alleviate pressure. This positioning and lack of tolerance to the completely turned to the patient's sides was not documented in the medical record. The supervising nurse did not monitor to ensure the patient's position was turned every two hours and accurate records of the patient's repositioning were documented.