HospitalInspections.org

Based on record review and interview the hospital failed follow the hospital Grievance policy and ensure grievance decisions were provided in writing to patients (or their representative) and included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This deficient practice was evidenced by no documented evidence of Grievance response letters for 4 of 4 (R1, R2, R3, R4) patient grievances reviewed for written decisions provided to the patient/patient representative.
Findings:

Review of hospital policy #12.8.0, titled, "Complaints and Grievances: Patient/Family", approved January 2018, provided by S3DON as current, revealed the following, in part:
" ...The investigation process for patient complaints or grievances must be initiated within 24 hours. The complaint/grievance resolution process shall take precedence over any and all previously scheduled activities, including but not limited to: administrative scheduled time off, provision of clinical are, and off-site meetings ... Procedure: ...4. In the case of a grievance (a complaint that cannot be resolved on the spot) the Manager/charge nurse/supervisor coordinates with other managers and/or the Patient Representative to investigate and formulate a final response ...5. In the case of a grievance, most situations will be resolved and the patient notified of the resolution within twenty (20) business days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the evaluation and the investigation into the grievance, and the date of completion (indicated by the date of the letter to the patient) ...7. In a situation requiring more extensive evaluation and investigation, written notice will be provided to the patient within twenty (20) business days stating that the situation is being investigated or corrective action is being evaluated, and that another written response will be sent by a certain date (depending on what actions need to be taken) ..."

Review of the hospital grievance log revealed, in part, the following grievances:

A grievance filed 4/14/18 by Pt R1 regarding the care received. Further review revealed no documentation regarding an investigation or findings, results of an investigation, or of written notification to the patient.

A grievance filed 5/11/18 by Pt R2 regarding an incident with another patient. Further review revealed no documentation of an investigation or results, or of written notification to the patient.

A grievance filed 6/1/18 by Pt R3 regarding privacy of information. Further review revealed no documentation of an investigation, or of written notification to the patient.

A grievance filed 7/10/18 7/9/18 by Pt R4 regarding him not being able to eat related to a medical diagnosis and the quality of the food. Attached was email correspondence from S4SSDirector to S3DON inquiring if the stated diagnosis was correct and if the food at the hospital would cause him to be ill. An email response from D3DON reported she was aware of the patient, and since the receipt of this grievance the NP had seen the patient and ordered medication before meals to prevent nausea. The email went on to say the patient had already been discharged, and could be sick from his previous diagnosis. Further review revealed no documentation regarding an investigation or a written response to the patient.


In an interview 7/17/18 at 4:45 p.m. S4SSDirector confirmed she was responsible for Grievances for the hospital. After a review of the above grievances, S4SSDirector verified that a written notice was not provided to the patient or patient representative in response to the grievance. She reported she thought that one was not necessary if the patient was still in the hospital. She verified that none of the grievances received by the hospital had a written notification of the hospital contact person, steps taken to investigate the grievance, the results of the grievance process ,and the date of completion sent to the patient/patient representative. She further verified that details regarding the investigation steps and results were not included in the grievance documentation. The hospital policy was reviewed and she verified the Grievance procedure was not being implemented according to hospital policy.

Based on record review and interview., the hospital failed to ensure the nursing staff developed, and kept current, an individualized comprehensive care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 4 of 4(#2, #3, #4, #5) sampled patients reviewed for care plans of a total sample of 5.
Findings:

Review of hospital policy #12.1.10, titled "Patient Rights", last approved January 2018 and provided by S3DON as current, revealed, in part, that all patients had the right to individualized treatment plans, with regular periodic review to determine progress and response to treatment.

Review of hospital policy #4.10.0, titled "Master Treatment Plan/Weekly update Treatment Plan", last approved January 2018 and provided by S3DON as current, revealed in part that the nursing assessment would be completed within 8 hours from the time of the patient's admission. Further review revealed treatment plans would be individualized to address patient specific problems identified through clinical assessments. The policy and procedure stated, "The delivery of effective care and services depend on the following four(4) key processes being performed well: 1. Formulating, maintaining, and supporting an individualized treatment plan. 2. Implementing the treatment plan. 3. Monitoring responses to the care and services. 4. Modifying the treatment plan as necessary to meet the changes in progress."



Patient #2
Review of the medical record for patient #2 revealed he was admitted 7/9/18 with increased progressive aggressive behavior and a history of Bipolar Disorder and schizophrenia. The patient's medication during admission included, in part, Ativan, Benadryl, Haldol, Zyprexa, Depakote, Invega, Trazodone, Invega Sustenna, and Lithium. Further review of the medical record revealed no care plan that included monitoring for possible side effects of his medications.


Patient #3
Review of the medical record for Patient #3 revealed she was admitted 6/22/18 for Depression,SI, and Anxiety. Further review revealed the patient also had diagnoses that included Bipolar Depression/Major Depressive Disorder, Fibromyalgia, arthritis, GERD, history of gastric bypass surgery,and a history of falls. The patient reported she had a lack of appetite. A patient fall was documented, in which a shoulder and right knee x-ray was performed. Further review revealed the treatment/care plan for the patient addressed her needs related to her medical problems as: "Problem/need: Existing Medical Problem- [Patient #3's] existing medical problem(s) has been identified as needing monitoring, as evidenced by: 'Carries a prior diagnosis by Medical Director' " Interventions were listed as: monitoring for symptoms and side effects, if any, and reported them to prescribing physician, administer medications and other treatments as ordered, and monitor and record compliance, effectiveness and side effects. Further review revealed no identification of specific needs related to her 'medical diagnoses', or treatments to be administered. Review of her "Fall Risk" care plan revealed a short term goal that the patient would report any symptom that might contribute to a fall such as dizziness or loss of balance, with a frequency documented as twice a day. The one intervention was that the nurse would provide ambulation assistance as required, with a frequency of twice a day. Further review revealed no change or update to the care plan after the patient was documented as having a fall 7/9/18, No care plan for pain, alteration in nutrition, or potential problems related to her diagnosis of GERD was noted.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted 11/2/17 for increased progressive bizarre behavior with diagnoses that included Hyponatermia, Benign prostatic hypertrophy, CAD, Altered mental status, Questionable malnutrition, history of MI, pacemaker, history of DVT, mild cirrhosis of the liver, Hyponatermia, history of recent viral encephalopathy and acute renal failure. He was documented as having an altered mental status on admission. Review of Nursing notes dated 11/4/17 at 1:00 p.m. revealed the patient ate 75% of his mechanical soft lunch fed to him. A nursing note 11/4/17 at 6:00 p.m. revealed the patient remained incontinent of urine and stool. Review of Patient #4's care plan revealed no care plans related to his nutritional status or special diet (mechanical soft as ordered), his altered mental status, his need for assistance with ADLs including having to be fed, potential of DVT(s), altered electrolyte balance (Hyponatermia), monitoring for side effects of psychotropic medications, or his incontinence of bowel and bladder

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital 4/15/18 and discharged 4/22/18. Further review revealed she was admitted for complaints of depression, Suicide attempt, and self harm. She had used a razor to cut both arms, which required sutures to both arms in an ED prior to being transferred to this hospital. The sutures were in place on admission. Patient #5 was documented on the admission nursing assessment to have a history of a Thyroidectomy and Gastric Bypass, and was taking Synthroid and Neurontin on admission. Her H & P documented Hypokalemia, Elevated WBC, Abnormal EKG, Constipation, and Sutures. The H & P documented, in regards to the sutures, the patient would be showered daily. Further review of the patient's care/treatment plan revealed a care plan for "Existing Medical Problem" as evidenced by "Is taking medicine for existing condition". No further identification of specific condition or conditions was noted. No nursing plan of care was noted for, in part, the patient's multiple wounds and sutures to her arms, a potential for infection, related to her need for prescribed thyroid replacement, constipation, or altered electrolytes.




In an interview 7/17/18 at 2:45 p.m., after review of patient medical records, S3DON confirmed that the findings on Patients 2, 3, 4, and 5. She confirmed care plans were not complete and individualized. S3DON stated the nursing care plans for hospital patients focused on the psychiatric diagnoses. She agreed that the nursing portion of a patient's care plan should include all the patient's nursing needs, not just those related to their mental health, and should have specific interventions for each patient's needs.

Based on record review and interview, the hospital failed to ensure patient care personnel were qualified and competent to provide care to each patient as evidenced by failing to have documented evidence of ongoing in-servicing for 2 of 2( S8MHT, S9Dietary ) personnel files reviewed with employment over 1 year, skills competency testing for 4 of 4(S3DON, S5RN, S7SW, S8MHT) personnel files reviewed for current competencies, and annual evaluations for 1 of 1( S8MHT) personnel files reviewed for annual evaluations of personnel employed greater than one year.
Findings:

Review of hospital policy and procedure #1.4.0, titled, " Determination of Clinical Competency", last approved January 2018 and provided by S3DON as current, revealed in part, all staff would demonstrate the appropriate knowledge and skills necessary to provide quality care/service appropriate to the age/disability related needs of the patients served. Clinical competency would be determined by the clinical supervisor of the employee. Further review revealed "Certain designated assessment of competency is required prior to performing direct patient care and certain designated assessment of competency is required 30 days after date of third unsupervised shift worked."

Review of the personnel files for S3DON , with a date of hire of 5/2/18, revealed no documented evidence clinical competencies.

Review of the personnel file for S5RN, with a date of hire of 5/7/18, revealed no documented evidence of a competency assessment.

Review of the personnel files for S7SW with a date of hire of 2/19/18, revealed no documented evidence of a competency assessment, or completed orientation documents.

Review of the personnel files for S8MHT, with a date of hire of 8/29/18, revealed no documented evidence of an annual performance evaluation since 2015. Further review revealed no documentation of current competencies, and annual in-services/education within the last 2 years.

Review of the personnel file for S9Dietary, with a date of hire of 6/29/10, revealed no annual in-services or hospital education in the last year.


On 07/17/18 at 4:45 p.m., in an interview with S1ADM, S2AADM, S3DON, and S4SSDirector, S3DON and S4SSDirector confirmed the hospital did not evaluate competency skills assessments for staff providing care and services to patients. S1ADM, S2AADM, S3DON, and S4SSDirector verified the hospital did not provide annual education and in-services to hospital staff related to, in part patient rights, grievance procedure, Abuse and Neglect, and Patient Privacy/HIPAA. S1ADM verified S8MHT did not have a performance evaluation for the last 2 years in her file.