HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the effective operation of the grievance process for one of five patients reviewed with a grievance (Patient 1). When Patient 1 notified the hospital of his dissatisfaction regarding care in the ED for a burn, the hospital's response did not show all of the allegations in the grievance were addressed and the grievance response was not supported by the documentation in the medical record. In addition, the hospital's investigation did not show documentation all avenues of inquiry were used in the investigation when the physicians who provided the patient's care were not interviewed regarding specific allegations of physician behavior. These failures created the risk of a poor grievance response for the patient.

Findings:

The hospital's P&P titled Complaints and Grievances, Formal, revised in 1/13, read in part, "Grievances will be forwarded to the appropriate departments, management team, and directors for investigation and resolution via the incident reporting system." "Grievances in the category of Quality of Care or Physician Behavior will be concurrently reported to Performance Improvement for review of potential quality issues," and "Throughout the process, patient rights and responsibilities are emphasized and appropriate information given regarding the options available and stages of the resolution."

On 4/15/13, patient grievances were randomly selected for review from a list of grievances dated September, 2012. Patient 1's grievance, opened on 9/13/12, included billing, professional conduct and quality of care issues.

Patient 1's grievance was reviewed on 4/15/13. The file contained a letter from Patient 1 dated 8/30/12. The patient alleged he came to the ED on 8/15/12, for treatment. The patient was told a burn nurse would treat his hand in 40 minutes; however, the burn nurse did not arrive. The patient stated he received no wound treatment for the hand and stated his pain was not addressed. The patient reported the physician treated him coldly and told him to leave. Patient 1 wrote he subsequently went to another hospital and was satisfied with his treatment there.

In a review of the hospital's response to the patient dated 11/1/12, the letter asserted his care was subject to "thorough analysis." The letter showed the hospital determined Patient 1 received "accurate wound care: cleaning, topical Santyl and Polysporin ointment, dressing, and tetanus immunization."

Patient 1's medical record for the 8/15/12 visit was reviewed. The record showed Patient 1 had a burn involving his right palm and second through fourth digits. The patient did not receive wound cleaning or the application of ointments. A xerofoam dressing was placed by the wound care doctor who also ordered cleaning of the wound and application of Santyl and Polysporin antibiotic ointments by the burn nurse. Orders for Santyl and Polysporin ointments were in the record but were noted as "not performed" on the Medication Administration Record.

The medical record showed documentation the burn specialist recommended the wound be cleaned and treated by a burn nurse; however, there was no documented evidence to show a burn nurse was contacted to see the patient. There was no documentation to show the plan was changed to have the ED nurse provide the care. Nursing notes at 1700 hours, indicated the patient refused to cooperate with the ED nurse's offer to provide wound care and left the ED.

Patient 1's medical record showed the patient was assessed as having a pain level of 5 on a scale of 0 to 10 (0 = no pain and 10 = worst pain). The documentation was noted without a time; however, the note appeared to be from the time of triage at 1518 hours, as it also contained other vital signs from the time of triage. There was no documentation to show the patient's pain was reassessed with further characterization of the pain or discussion of whether the pain was tolerable for the patient during his stay in the ED. There was no documentation to show pain medication was offered to the patient.

Review of documentation in Patient 1's grievance file did not show the patient was contacted to determine which physician told him to leave the ED. The documentation did not show the physicians involved in Patient 1's care were interviewed regarding the allegation a physician told the patient to leave the ED. Documentation in the investigation showed a nurse interviewed stated she did not tell the patient to leave; however, the patient's allegation was that a physician not a nurse told him to leave.

During an interview with the RN Director of the ED on 4/17/13 at 1250 hours, the Director reviewed the medical record of Patient 1. The Director confirmed wound cleaning and application of the Santyl and Polysporin ointments was not documented in the patient's record.

In an interview with the Director of Quality on 4/18/13 at 1045 hours, she acknowledged Patient 1's grievance response letter did not match the documentation in the medical record regarding wound care.

During an interview with the Emergency Medicine Department Chair on 4/18/13 at 1330 hours, the physician reviewed Patient 1's record. The Department Chair stated he was not sure if the burn nurse was called to see the patient.

The Assistant Director of Patient Experience was interviewed on 4/18/13 at 1345 hours. The Assistant Director stated she tried to see if the grievance review matched up with the ED documentation. When asked, the Assistant Director was unable to identify a process for determining whether all of the Patient 1's grievance allegations were addressed.

Based on interview and record review, the hospital did not ensure the attending physician had signed the consent for a surgical procedure for one of 40 sampled patients (Patient 4), creating the risk of a poor health outcome for the patient.

Findings:

The hospital's P&P titled Surgical/Procedural Informed Consent, Attachment B, effective 6/8/11, read in part, "After the informed consent discussion has taken place, written verification will be obtained and documented on the Consent for Operation/Procedures or Rendering of Other Medical Services form (exceptions to written documentation of informed consent are described on Attachment 'G'). The licensed physician or Physician Assistant member of the procedural team providing the information to the patient and the attending physician performing the procedure, must both sign/date the form."

The medical record for Patient 4 was reviewed on 4/15/13. The record contained a Consent for Operation/Procedures or Rendering of Other Medical Services form dated 3/30/11, for the procedure: "Right knee irrigation and debridement and inset replacement total knee arthroplasty, possible explant and antibiotic spacer knee." Section II of the form contained an area for documentation of the physician's statement of informed risks and complications. The form contained the signatures of the patient and the resident physician; however, there was no documentation to show the attending physician performing the procedure and supervising the resident had signed the form.

In an interview with the Director of Perioperative Services on 4/15/13 at 1410 hours, the Director reviewed the consent form and concurred there was no signature of the attending physician.

Based on interview and record review, the hospital failed to ensure pain was assessed and managed for two of three ED patient records reviewed (Patients 1 and 7), creating the risk of substandard health outcomes for the patients.

Findings:

The hospital's P&P titled Pain: Adult and Pediatric, effective 4/11, read in part, "Screen for the presence of pain upon admission or with first contact with the patient." "Determine pain scores using patient's self-report and pain assessment tools." "A complaint of pain greater than 4, or a complaint of pain greater than usual for the patient or ineffective pain management, requires a more in-depth assessment or self-report to be completed." "Nurse will notify physician if during initial assessment patient's pain score is greater than 4 if no pain medications are ordered." "Interventions may include pharmacological and/or non-pharmacological measures to relieve the patient's complaint of pain, and should be initiated whenever the patient's current pain rating exceeds their pain goal or is greater than 4 on a 0-10 scale." and "Document all pain assessments, reassessments, and interventions on the unit specific flowsheet, PCA (pain controlled analgesic) flowsheet and/or in clinical information systems."

1. The medical record of Patient 1 dated 8/15/12, showed the patient came to the ED with a burn to his right hand. On the ED Flowsheet the patient was assessed as having a pain level of 5 on a scale of 0 to 10 (0 = no pain and 10 = worst pain). There was no time or date on the form to indicate when the patient's pain was assessed. There was no documentation to show the patient was reassessed for pain, pain medication was offered to the patient, or a discussion occurred as to whether the pain was tolerable for the patient. There was no documentation of communication between the ED nurse and physician regarding the patient's pain. The nursing assessment, completed at 1730 hours, (36 minutes after the patient left the ED) in the electronic medical record contained no pain assessment.

In a grievance letter dated 8/30/12, Patient 1 reported he left the ED without treatment and with "a lot of pain.".

In an interview with the Emergency Medicine Department Chair on 4/18/13 at 1330 hours, Patient 1's medical record was reviewed. The Department Chair stated there was no documentation to show the staff had asked the patient if he needed treatment for pain.

2. The medical record for Patient 7 was reviewed on 4/18/13. The patient came to the ED with traumatic injury to the knee from a fall on 9/7/12. The ED Rapid Screening Exam completed at 1855 hours, showed the patient's chief complaint was "left knee pain s/p (status post) slip and fall 15 mins ago." There was no further characterization of the patient's pain and no pain score was documented. No follow-up nursing assessment was found in the record.

On 9/8/12 at 0450 hours, approximately 10 hours after arrival, documentation showed the patient left the ED without being seen.

In an interview with the RN Director of the ED on 4/17/13 at 1250 hours, she stated the patient's pain level score should be documented during the Rapid Screening Exam.

Based on record review and staff interview, the hospital failed to ensure competencies were established and nursing staff received specialized training to care for patients admitted to the Acute Rehabilitation Unit with brain trauma and spinal cord injuries in order to provide safe patient care.

Findings:

During a tour of the Acute Rehab Department on 4/16/13 at 0850 hours, the Unit Manager stated the unit provided rehabilitation for orthopedic and stroke patients as well as rehabilitation for brain trauma and spinal cord injury patients. When asked if the staff was provided any special training for the care of the spinal cord injury and brain trauma patients, the Unit Manager stated no special training was provided.

Review of the Acute Rehab Unit Orientation Manual showed a Master Competency List. The list showed the nurses were competent in the care of general medical/surgical patients; however, there were no competencies for the care of spinal cord injury and brain trauma patients.

An example of specialized training for staff caring for spinal cord injury patients would be training to recognize symptoms of autonomic dysreflexia in patients with spinal cord injuries that involve the thoracic (T) nerves of the spine or above (T 6 or above).

Per the WebMD website, autonomic dysreflexia is a syndrome that can develop when there is a sudden onset of excessively high blood pressure. If not treated promptly and correctly, it may lead to seizures, stroke and even death. Autonomic dysreflexia is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T 6 or above).

Based on interview and record review, the hospital failed to provide discharge planning counseling to meet the needs of one of 40 sampled patients (Patient 4) when the patient was not provided timely information regarding the discharge plan and the different options for obtaining required care after discharge, creating the risk of loss of well-being for the patient.

Findings:

The hospital's P&P titled Interdisciplinary Discharge Planning, revised in 3/13, read in part, "The Medical Center provides interdisciplinary discharge planning services to patients and their families, throughout the continuum of care." "This process shall reflect each patient's individual needs regarding age specific, disabilities, cultural, spiritual, psychosocial and medical condition."

In an interview with Patient 4 on 4/15/13 at 1345 hours, the patient stated he informed the hospital upon admission that he was not working and was uninsured. Patient 4 stated he had a surgery on his leg on 4/11/13, due to an infection. Patient 4 stated he had a PICC line, and was to receive antibiotics as an outpatient for several weeks. The patient stated he was not sure how he would be able to pick up and pay for the antibiotic medication at home as well as how he would obtain laboratory follow-up of his antibiotic treatment.

Patient 4 stated he was told he would be discharged when the culture results were available and the results were available today (4/15/13); however, he stated he was not sure if he was being discharged today and was anxious about his post-discharge care. Patient 4 stated the Social Worker just picked up his insurance application today. The patient stated he felt there should have been a sooner response to his questions if he needed emergency medical insurance. Patient 4 stated he let the Floor Manager know of his concerns and the Floor Manager agreed to relay them to the patient's Case Manager.

The Case Manager was interviewed on 4/15/13 at 1405 hours. The Case Manager stated she spoke with the patient the previous week and was working on getting emergency funding for him. The Case Manager stated the discharge was discussed with the patient; however, she stated she did not inform the patient he would not be discharged until a source for payment of outpatient antibiotics was confirmed. The Case Manager stated she wanted to encourage him to bring in the documentation needed for the insurance application. The Case Manager confirmed it was her job to keep the patient apprised of discharge planning.