HospitalInspections.org

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the administrator failed to require that the hospital implemented their Grievance/Complaint investigation and resolution process for 2 of 2 patients (Pts. #8 and 14).

Findings include:

The hospital policy titled Complaint And/Or Grievance Resolution Process - Regarding A Patient #HP100-07 (revised 03/02/09) requires, "...Grievance...A verbal complaint regarding a patient's care when the 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 formal investigation, and/or requires further actions for resolution...Within 7 days of receiving the grievance, the Patient Relations Coordinator will generate a letter to the complaintant, which states that the grievance has been received and is being investigated and provides a follow-up contact name and phone number...When a resolution is reached by the (hospital) Grievance Committee, the disposition of the matter...will be communicated to the complaintant in written form. The letter will include the name of the (hospital) contact person, the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion...The patient or patient representative will be notified of the final grievance resolution within ninety (90) days of the grievance being received (actual date noted) in the patient relations office...."

The Patient Relations Coordinator stated during an interview conducted on 03/11/10 at 1120, that "only documented complaints are grievances", therefore the following complaints were not handled as grievances, per policy requirement:

1. Pt. #8: The Confidential Information (incident report) revealed a complaint received per phone call on 08/12/09, concerning damage to the patient's hearing aid related to the actions of the nursing staff during the 08/05/09 through 08/07/09 hospitalization.

The Patient Relations Coordinator stated during an interview conducted on 03/11/09 at 1120, that s/he "rounded" on the patient twice daily during the hospitalization because the patient's representative verbalized multiple complaints but would "never sit down and fully discuss them."

There was no documentation that the complainant was provided a written acknowledgement of the complaint within 7 days of receipt to include a follow up contact name and phone number, written disposition of the grievance to include the name of the (hospital) contact person, the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion, or documentation to confirm that the patient or patient representative was notified of the final grievance resolution within ninety (90) days of the grievance being received, according to the hospital's policy/procedure.

2. Pt. #14: The Patient Relations Coordinator stated during an interview conducted on 03/11/10 at 1120, that s/he was initially involved with the complainant regarding multiple patient care concerns, related to the 12/18/08 through 12/19/08 hospitalization, however was physician-directed to discontinue contact with the complainant and refer him/her to the Director of the Spine and Joint Program. The Coordinator had no further contact.

The Director of the Spine and Joint Program confirmed during an interview conducted on 03/11/2010 at 1230, that s/he had telephone contact with the complainant.

There was no documentation that the complainant was provided a written acknowledgement of the complaint within 7 days of receipt to include a follow up contact name and phone number, written disposition of the grievance to include the name of the (hospital) contact person, the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion, or documentation to confirm that the patient or patient representative was notified of the final grievance resolution within ninety (90) days of the grievance being received, according to the hospital's policy/procedure.

Based on observations during tour, review of hospital policy/procedure, and staff interviews, it was determined that the hospital failed to require that privacy curtains be provided for all patients.

Findings include:

The Patient/Surrogate Rights and Responsibilities #HP100-01 requires: "...Patient/Parent/Guardian...Has the right to personal privacy...."

The following observations were verified during a tour of random patients' semi-private rooms, conducted with the Director of Medical/Surgery, Chief Nursing Officer (CNO), and the Charge Nurse on 03/11/10 at 1445:

Rooms 3016, 3018, 3012, 3081, 3082, 3080, and 3078, were all missing privacy curtains for the patients in the 2nd bed (B-2).

According to the hospital's Project Coordinator, the curtains were eliminated "about 10 years ago." The curtains around the 1st patient bed (B-1 ) were intended to also provide privacy for B-2. However per observation, a single curtain cannot provide privacy for both beds when needed at the same time, leaving the patient in B-2 exposed.

Based on review of medical records, policies/procedures, and interview with staff, it was determined a registered nurse did not evaluate and supervise the nursing care for patients as evidenced by:

1. Nursing did not reassess pain for a pediatric patient with a fractured leg (Pt #6);
2. Nursing did not reassess pain for 2 of 4 patients (Pts #10 and 12) with pain in the emergency department (ED) on 03/02/10 and 03/03/10; and
3. Nursing did not provide, or document, Pt #6's daily personal hygiene.

Findings include:

The hospital's policy titled Management of Acute and Chronic Pain, required: "...Pain is assessed in all patients...Assessment and Management of Pain in the Pediatric Patient...To determine optimal analgesic intervention for pain management in the pediatric patient, developmental age...3-6 years: Child will point to the face that best represents the degree of pain felt. Will utilize an expressive face scale 'Smiley Face Scale 0-5' or 'Faces Pain Scale-Revised'...Pain management must include documentation of response to interventions: pharmacological and nonpharmacologic...Effectiveness of comfort measures or pharmacologic intervention will be assessed and documented on the designated flow screen in the automated medical record...."

The hospital's policy titled Triage Nurse Responsibilities required, "...Assess all incoming patients...Routinely re-assess patients awaiting bed placement in the main ED...."

1. Pt #6, a pediatric patient, was admitted to the ED on 01/21/08 at 2:51 PM, with complaints of left shin pain after running into a sign post while sledding. Triage nursing assessed the patient's pain as a # 6 (scale 0-10, 10= worst pain ever). The patient was discharged at 9:53 PM, with a long leg posterior splint.

Documentation in the medical record did not indicate the nursing staff had communicated the patient's pain to the physician prior to the physician's examination at 7:00 PM, nor did nursing document a reassessment of the patient's pain for the entire 7 hour ED stay.

The ED physician examined the patient at 7:00 PM, approximately 4 hours after arrival. The ED record contained four different medication orders, none of which were timed when written. It is unknown when the physician ordered any of the medications. Nursing documented administering the Tylenol with codeine pain medication at 7:05 PM along with a medication (Zofran) to prevent nausea.

The ED physician had ordered Tylenol with codeine elixir for pain and indicated this could be repeated one time, if needed, it was not repeated. The ED physician also ordered Ibuprofen for pain which was administered at 8:26 PM. A third medication was ordered for pain, Lortab elixir, that nursing did not administer.

The ED Charge Nurse confirmed on 03/10/10, at 1:50 PM, nursing did not follow the hospital's policy and reassess the patient after pain medications, nor did they reassess the patient and obtain a pain level assessment after the initial triage occurred at 2:44 PM.

2. ED records were reviewed for pain assessment and management to determine the current practice in the ED. A total of 4 medical records from the previous week were reviewed with the ED Charge Nurse. Of those 4 records, 2 of 4 did not contain documentation of patients' reassessments for pain (Pts #10 and 12). The ED Charge Nurse confirmed nursing did not reassess the patients' pain according to hospital policy and confirmed the findings.

3. The hospital policy titled Daily General Patient Hygiene #HP300-95 requires: "...Every inpatient is offered a bath or shower and the linens are changed on a daily basis unless contraindicated by his/her condition. Daily hygiene care includes oral care, skin care, shaving, peri care, Foley care, and PM (evening) care...Document in the documentation system anytime patient hygiene is provided...."

The Charge Nurse confirmed that there was no documentation to conclude that Pt. #8 was provided daily hygiene at any time during hospitalization, 08/05/09 through 08/07/09, at the time of the medical record review and interview conducted on 03/11/2010.