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Based on review of facility documents and staff interview, it was determined that the facility failed to implement its "Patient Grievances and Complaints" policy, in one of one complaint and grievances reviewed (Patient (P) 1).

Findings include:

On 1/22/24 review of the facility document "Clinical Incident" for P1 stated "Comments Complaint-phone call received by patients [son/daughter] regarding the care of her mother while at [facility name] ..."

Upon interview with Staff (S) 1, the Vice President of Nursing, on 1/22/24 at 1:20 PM, he/she indicated the Clinical Incident was considered a complaint and was "resolved in house." S1 confirmed according to the facility policy, the telephone verbal complaint would be considered a grievance.

Facility policy titled, "Patient Grievances and Complaints" (effective 11/2019), stated, " ...3. Grievance: A written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by the staff present) by a patient or the patient ' s representative regarding the patient ' s care ...4. Examples of Patient Grievances: ...Patient complaints that are considered grievances also include situations where a patient or a patient ' s representative telephones the hospital with a complaint regarding the patient ' s care ...Procedure for using the Event Report-Complaint and Grievance From or online reporting in the event reporting system ...6. The complaint or grievance form is forwarded to the applicable Department Manager immediately for review and action ....7. The Department Manger completes any investigation, identifying if the issue has been resolved or not resolved, corrective actions taken and any needed notifications of other personnel for follow up. ...12. The CEO is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion. ...14. Verbal or written response shall be forwarded to the patient or patient representative no later than 7 business days after receipt of the grievance ..."

The facility was unable to provide any documentation of an investigation or follow up response to the grievance.

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure an organized nursing service, where staff were properly trained prior to performing an invasive procedure in one of 10 Medical Records (Patient (P) 1) reviewed (A-0397).

Cross Reference:
482.23(b)(5) Nursing Services: Patient Care Assignments

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure staff were properly trained prior to performing an invasive procedure in one of 10 Medical Records (Patient (P) 1) reviewed.

Findings Include:

On 1/3/23 at 11:10 AM, P1 presented to the Emergency Department (ED) via ambulance for increased shortness of breath over a period of two days. P1 was admitted to a telemetry bed on 1/3/23 at 1:50 PM for Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung diseases) exacerbation, acute respiratory failure with hypoxia (a serious condition when the lungs cannot release enough oxygen), and influenza A (a type of virus that causes the flu).

On 1/8/23 at 7:59 AM, P1 was transferred to the Intensive Care Unit (ICU) after a rapid response was called for hypoxia (a condition in which the tissues are deprived of oxygen).

On 1/23/24, review of P1's medical record was conducted in the presence of S4, a Nurse Educator.

On 1/10/23 at 11:00 AM, P1's provider placed a nursing communication order for the nurse to insert a Dobhoff tube (a small lumen feeding tube advanced into the duodenum) for feeding.

The medical record lacked documented evidence of the time the Dobhoff tube was inserted.

An order for a STAT x-ray to confirm Dobhoff tube placement was placed on 1/10/23 at 1:28 PM. Findings for this x-ray were initially read by the Radiologist on 1/10/23 at 2:54 PM. The initial reading did not acknowledge the Dobhoff tube placement. An addendum was added on 1/10/23 at 3:02 PM which stated, " ...Correction. Current film was reviewed. The feeding tube extends into the right lower lung. ICU notified by telephone ..." The medical record does not indicate if the Dobhoff tube was used prior to x-ray results.

An order for STAT x-ray for examination after removal of Dobhoff tube was placed on 1/10/23 at 3:03 PM. Findings for this x-ray on 1/10/23 at 6:24 PM showed a moderate right pneumothorax. The report indicates that the radiologist notified the Advanced Practice Nurse (APN) of results at the time of dictation.

An ICU nursing note dated 1/10/23 at 6:30 PM stated, " ... [Radiologist name] will call [APN name] to inform [him or her] that there is a moderate pneumothorax in the right lung from dobhoff insertion - dobhoff pulled and repeat chest x-ray done ..." Based on nursing documentation, it was unclear at what time the Dobhoff tube was removed and S4 was unable to clarify the time during medical record review.

On 1/11/23 at 12:17 AM, a nursing note stated, "21:30 [9:30 PM]: patient was intubated, chest tube placed, and femoral line inserted. ..." On 1/12/23 at 1:23 AM, a nursing note stated, "Approximately around midnight patient was oxygen saturation was noted to drop to 83% and tachycardiac, respiratory therapist was called. ...Around 00.15 [12:15 AM] patient pulse was not palpable. Chest compression was started and code blue called. Completed multiple rounds of chest compression. Patient was pronounced dead at 00:35 [12:35 AM] ..."

An interview was conducted with S15, ICU Nurse, on 1/23/24 at 2:45 PM. S15 explained that he/she has been a nurse for 28 years and has placed Dobhoff tubes at other hospitals but had never received competencies or performed the procedure at this facility. S15 stated that prior to inserting the Dobhoff tube, he/she asked the supervisor if it was ok to insert the Dobhoff tube into P1. According to S15, the supervisor consulted with the nurse educator, and they ultimately approved the insertion. S15 stated that he/she inserted the Dobhoff tube and then P1 had the STAT x-ray to confirm placement of the tube.

On 1/23/24 at 1:15 PM, S15's personnel file was reviewed. The personnel file lacked evidence of training, education, or competency in inserting a Dobhoff tube.

The facility identified the above incident as a safety concern and developed an action plan. The action plan stated that education would be provided to nurses regarding a revised policy and a Dobhoff competency would be developed for (Advanced Practice Nurses) APNs and Physicians. This will be checked yearly during credentialing. Only APNs, Physician Assistants (PA) and physicians are permitted to insert a Dobhoff tube. Nurses are not allowed to insert a Dobhoff tube. The education provided to staff was requested and not received.

On 1/23/24 at 1:58 PM, S1, the Vice President of Nursing, stated that the facility was unable to locate a record of education provided to nurses and providers regarding the new policy on Dobhoff tube insertion. The Dobhoff tube policy that was in place at the time of the incident and the revised policy were requested from S1. The facility was unable to provide these policies. S1 confirmed that education was not provided to nurses and providers and there are no policies regarding Dobhoff tube insertion.

A list of patients with Dobhoff tubes in the last 3 months was requested of S1. S1 confirmed that there were no patients with Dobhoff tubes in the last 3 months.

On 1/23/24, interviews with S10, S12, S16 and S17, Registered Nurses (RNs) and S11, a physician, confirmed that Dobhoff tubes are only to be inserted by a physician, APN, or PA.