HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) complaint and/or grievance record reviewed, the Hospital failed to ensure that the complaint and grievance process was followed, as required.

Findings include:

1. On 9/11/18 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 70 year old male admitted to the Hospital with a diagnosis of pneumosepsis (infection of the lungs).

2. On 9/11/18 at approximately 2:30 PM, the Hospital's policy titled, "Resolving Patient/Family Complaints & Grievances" (reviewed 10/2016) was reviewed and included, "... B. Grievance - a grievance includes any of the following... 3. All written complaints ... regarding: a. Patient Care... D. Management of Grievances... 3. Grievance Resolution a. A grievance is considered resolved when the patient or their representative is satisfied with the actions taken on their behalf. b. In situations where the patient or their representative remains dissatisfied with the resolution, despite an appropriate and reasonable investigation, the site may consider the grievance closed. 4. Written Response to a Grievance: a. Once the grievance is resolved, the patient or their representative will be provided with a written response, which will include: 1. Name of the site contact person; 2. Steps taken on behalf of the patient to investigate the grievance; 3. The result of the grievance process; 4. Date of completion. b. The written response will be communicated to the patient or their representative in a language and manner that they understand. c. Copies... of the site's written response to a grievance will be maintained..."

3. On 9/11/18 at approximately 3:00 PM, Pt. #1's "Complaint and Grievance Resolution Report" was reviewed and included, " ... The issue pertains to... Nursing Care... Physician Care... Patient Relations received the following information related to this concern: 8/17/18 by (E #24/Patient Relations Specialist)... Patient Relations received the attached letter from (Pt. #1's) spouse and family..." The Complaint and Grievance Resolution Report included that E #8 (Clinical Manager) met and spoke with Pt. #1's wife and brother regarding hip surgery... not wanting to be discharged to a nursing home...

4. On 9/12/18 at approximately 9:44 AM, an interview was conducted with E #24. E #24 stated that a grievance is a written complaint when a patient has been discharged from the Hospital. E #24 stated that she (E #24) had followed up with E #8 (Clinic Manager) who had the impression that Pt. #1's spouse was satisfied with the "resolution of the complaint." E #24 stated that there was no written response sent to Pt. #1's family regarding the "resolution of the complaint."

5. On 9/12/18 at approximately 10:30 AM, an interview was conducted with E #8 (Clinical Manager). E #8 said, "I received the complaint on 8/17/18 ... spoke with (Pt. #1's) wife and brother ... Discussed complaint regarding (Pt. #1's) care ... plan for hip surgery ... not wanting to be discharged to a nursing home ... Discussed with family about having multidisciplinary care conference ..." After meeting with the spouse, E #8 said, "They seem to accept but still not happy with the plan ..."

Based on document review and interview it was determined that, for 2 of 3 (Pt #2 and Pt #3) patients, on Neurology Stroke Unit, Hospital failed to ensure preventive measures are in place to prevent development of Hospital acquired pressure ulcer.

Findings include:

1. The Hospital policy titled, "Skin Integrity: Care and Treatment of the Skin" (05/10/18) included, " ...1. Purpose: To provide guidelines for the promotion of skin integrity ...IV. Procedure ...2. Use the Braden Scale (skin assessment score) to assess ...change in level of care and every 24 hours."

2. The document titled, "Flow Sheet" (07/20/18) documentation by a Registered Nurse, included that Pt #2's Braden Score (skin assessment score) of 10. The legend included, "Patient score of less than 19, patient is at risk for skin break down." The skin assessment documentation on admission (07/20/18) included, "Left foot -3rd toe abrasion, left foot - 4th toe abrasion, right foot - greater toe abrasion, left buttock cheek -abrasion, right foot -3rd toe abrasion." The skin assessment documentation (08/01/18) included, "Left and Right heel redness." The skin assessment documentation (08/23/18) included, "Sacrum partial thickness abrasion."

3. The document titled, "Flow Sheet" (08/23/18) documentation by a Registered Nurse, included that Pt #3's Braden Score (skin assessment score) of 17. The skin assessment documentation on admission included, "Wound to the Left foot with moderate wound drainage." The skin assessment documentation (08/28/18) included, "Sacral partial - moisture associated dermatitis. The skin assessment documentation (09/11/18) included, Braden Score (skin assessment score) - 12."

4. On 09/11/18 at approximately 2:07 PM, E #6 (Registered Nurse) was interviewed. E #6 stated, "Pt #2's Braden Score (skin assessment score) was 10 on admission. Anytime the score is less than 19, they are at risk for skin breakdown. Pt #2 came with skin abrasion to her left and right foot. But, Pt #2 developed the first stage of pressure ulcer injury to both heels on 08/01/18 and on 08/23/18, she developed sacral partial thickness abrasion. Yes, it could have been avoided, if we turned her every two hours."

5. On 09/11/18 at approximately 2:30 PM, E #7 (Charge Nurse) was interviewed. E #7 stated, "We try our best to prevent pressure ulcers from developing. We have a form HAPI (Hospital Acquired Pressure Injury) that is completed as soon as we find out about pressure ulcer that is acquired at the Hospital. We do extra measures to prevent further pressure ulcers from developing."

6. On 09/11/18 at approximately 2:38 PM, E #8 (Clinical Manager-Neurology-Stroke Unit) was interviewed. E #8 stated, "We should never have Hospital acquired pressure injury. It is a never event. We do spot checks on documentation and preventative measures."

7. On 09/11/18 at approximately 2:50 PM, E #9 (Registered Nurse) was interviewed. E #9 stated, "Ideally, we must avoid pressure ulcer developing in a Hospital. We do the Braden Score (skin assessment score) every shift. Yes, Pt #3's Braden Score is decreased to 12 and she has developed sacral partial thickness breakdown that is associated due to moisture."