HospitalInspections.org

Based on interview, and review of policies and procedures and other admission documents, it was determined that the hospital failed to implement a clearly explained procedure for the submission of, and response to, patients' grievances. Grievance information provided to patients contained unclear and contradictory information related to the submission of complaints/grievances about violations of civil rights versus any aspect of care or treatment; the right to submit verbal and written complaints/grievances; and a patient's right to receive a written response to a complaint/grievance.

Findings include:

1. The hospital's "Patient Complaints/Grievances" policy effective 01/06/2011 reflected "To establish a process to promptly and fairly address patient complaints and grievances regarding patient care...Patient or patient's representative may inform the hospital of dissatisfaction by...Telling any staff member of their concern...Contacting the department manager with primary responsibility for resolution of a complaint/grievance by calling or writing a letter directed to the facility where the incident occurred...If the grievance is resolved within seven (7) days, the Risk Manager will draft a letter to the patient with written notice of the hospital's decision...If the grievance is not resolved within seven (7) days, the grievant should be informed that staff are still working to resolve the grievance and that a written response will be provided within thirty (30) days."

None of the documentation contained within the "Patient Complaints/Grievances" policy included provisions for informing patients of the grievance process.

2. Review of the "Rights and Responsibilities" documents contained in hospital admission packets provided to patients reflected "Our patients have the right...to complain about hospital care without fear of reprisal and if requested, to receive a written response from the hospital. Patients or their loved ones may contact the Risk Management Department...for additional assistance and/or to request a copy of the PeaceHealth Oregon Region Grievance Policy. This information was contradictory to the hospital's "Patient Complaints/Grievances" policy referred to above which required a written response to a grievance.

3. The inpatient psychiatric unit admission packet was reviewed. The packet included handouts which contained grievance information. Those handouts included the previously mentioned "Rights and Responsibilities," and a 17-page "Welcome" handout.

The "Welcome" handout had "Grievance Process" on pages 15-16 which reflected "...you may initiate a grievance process. The procedure is outlined below. If you need any type of assistance with the grievance process, please contact Risk Management...Patient provides, in writing, a complete account of incident(s) they believe constitutes a violation of their civil rights...Submit the above written grievance to the Charge Nurse, who in turn forwards the document to the Nurse Manager or Clinical Operations Manager or designee the next working day...The Nurse Manager, Operations Manager or designee will review all pertinent documents...to formulate a written response to the grievance and submit this to the affected patient [within] three (3) working days of receiving the grievance."

The "Grievance Process" information provided to patients contained unclear information related to the submission of complaints about violation of civil rights versus any aspect of care or treatment. Patients received unclear and contradictory information regarding timelimes for a written response to a grievance and the submission of a verbal vesus a written grievance as reflected in the hospital's "Complaints/Grievances" policy referred to above.

4. An interview was conducted with the hospital's Center for Healthcare Improvement Director and the Risk Manager on 12/07/2011 at 1240. The director confirmed that the "Grievance Process" information and the "Rights and Responsibilities of Patients" were provided to patients during the admission process. He/she revealed that the "Grievance Process" information did not reflect the current procedure.

Based on policy and procedure review and the review of documentation, it was determined that the hospital failed to fully formulate and implement policies and procedures which addressed patient visitation rights; patients were not provided with their visitation rights as required.

Findings include:

1. A policy titled "Patient Rights and Responsibilities, Statement of," dated as effective 04/07/2010 was reviewed. The policy reflected "Purpose: To inform patients and employees of the rights and responsibilities of all patients and their parents or guardians." The policy included a listing of patient rights. None of the documentation contained information regarding the visitation rights of patients or required that patients be provided a notice of their visitation rights.

2. A policy titled "Visitation," dated as effective 07/19/2010 was reviewed. The policy focused on guidelines for visitation hours and number of visitors. None of the documentation included a procedure for informing patients of their visitation rights or required that patients be provided a notice of their visitation rights including their right to receive visitors whom they designated, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and their right to withdraw or deny such consent at any time.

3. Emergency Department (ED), Inpatient, Psychiatric Inpatient, and Rehabilitation Admission packets were reviewed. Some of the packets contained a booklet titled "Guide to Guest Services" which described "Visiting Hours" on page seven. Patient rights related to visitation as required by this regulation were not included.

Additionally, each packet contained a list of patient rights and responsibilities. The list lacked documentation of patient visitation rights along with their other rights, including the right to receive visitors he/she designated, including, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his/her right to withdraw or deny such consent at any time.

4. An interview was conducted with the hospital's Center for Healthcare Improvement Director on 12/07/2011 at 1310. He/she revealed that no documentation regarding patient visitation was provided to ED patients.

Based on review of policies and procedures, it was determined that the hospital failed to define a system for notifying the attending practitioner when an autopsy is performed.

Findings include:

1. PeaceHealth Oregon Region Medical Staff Services "Autopsy Policy," last reviewed 02/28/2011, clearly identifies the circumstances when an autopsy should be secured and the mechanism for documenting permission to perform an autopsy. However, there is no system identified for notifying the medical staff, specifically the attending practitioner when an autopsy is performed per regulation..

2. PeaceHealth Oregon Region Patient Care Services Policy "Death, Care of the Deceased," last approved 12/02/2011, outlines rules concerning determination of death and protocols to be followed. There is no system identified for notifying the attending practitioner when an autopsy is performed per regulation.

Based on the review of documentation in 5 of 5 medical records (Record #s 6, 7, 8, 9 and 10) of patients who received transfusions of blood or blood products, and policy and procedure review, it was determined that the hospital failed to ensure documentation of all of the elements required by the hospital's policy.

Findings include:

1. The policy titled "PeaceHealth Oregon Region Blood and/or Component Transfusion/Administration Procedure," dated as effective 07/20/2011 was reviewed and reflected "Transfusion...Before starting blood products each unit must be checked by two trained staff...Confirm that the consent has been signed and has been placed in the patient medical record...Verify patient name, Medical record number and date of birth are the same on both the CHART and TRANSFUSION RECORD...Verify number on blood bag is the same as unit number on TRANSFUSION RECORD...Confirm that there is a current order to transfuse and that the specific blood product to be infused matches physician's order...Verify blood type and Rh are the same on BLOOD BAG LABEL, TRANSFUSION RECORD and PATIENT CHART/ELECTRONIC MEDICAL RECORD...Registered nurse hanging blood will remain with patient for first five (5) minutes of transfusion...Patient will be observed frequently for next 15 minutes. A second set of vital signs will be obtained after 15-20 minutes and recorded on Transfusion Record...Following second set of vital signs, patient will be observed at least hourly for remainder of transfusion...Completing Transfusion...Complete TRANSFUSION RECORD and place in patient chart..."

2. Patient record #6 was reviewed and contained a form titled "Blood Transfusion Record 1: Cellular Products." The form reflected the patient received one unit of Packed Red Blood Cells (PRBC) on 08/23/2011 which was started at 0933. The vital signs section of the form contained spaces for recording the patient's vital signs and reflected "15-20 min after start of transfusion," and "At completion of transfusion." Review of the record reflected vitals signs were completed at 1000, 27 minutes after the blood transfusion was started.

The record reflected the patient received a second blood transfusion on 08/23/2011 which was started at 1120. The record reflected vital signs were completed at 1145, 25 minutes after the transfusion was started. Vital signs were completed again at 1300, 75 minutes later.

The 08/23/2011 nurse's notes reflected "[Patient] here for for PRBC'S. IV started...0933-1100. Both units of blood given without problems or concerns." None of the documentation reflected that the patient was observed hourly as directed by the hospital policy.

3. Patient record #7 was reviewed and contained a form titled "Blood Transfusion Record 1: Cellular Products." The form revealed the patient received one unit of PRBCs on 08/05/2011 which was started at 1310. The record reflected vital signs were completed at 1327. The blood transfusion and vitals signs were completed at 1445, 118 minutes later.

The 08/05/2011 nurse's notes reflected "1310-1445...PRBCs transfused without any complications, tolerated well." The record lacked documentation that the patient was observed hourly as directed by the hospital policy.

4. Patient record #8 was reviewed and contained a form titled "Blood Transfusion Record 1: Cellular Products." The form revealed the patient received one unit of PRBCs on 06/09/2011 which was started at 1032. The record reflected vital signs were completed at 1045. The blood transfusion and vital signs were completed at 1215, 90 minutes later.

The 06/09/2011 nurse's notes reflected "1032-1215; First unit of blood transfused. Tolerated Transfusion. VSS." The record lacked documentation that the patient was observed hourly as directed by the hospital policy.

Further review of the record revealed the patient received a second blood transfusion on 06/09/2011 which was started at 1308. The record reflected vital signs were completed at 1320. Vital signs were not completed again until 1430, 70 minutes later.

The area on the blood transfusion record form which reflected "Reaction observed? Yes/No" and "Infusion Volume? [checkbox] Complete" were not marked. The 06/09/2011 nurse's notes reflected "1305-1435; Second unit of blood transfused. Tolerated transfusion. VSS." The record lacked documentation that the patient was observed hourly as directed by the hospital policy; and the record lacked documentation whether or not the patient had an adverse reaction to the blood transfusion.

5. Patient record #9 was reviewed and contained a form titled "Blood Transfusion Record 1: Cellular Products." The form reflected the patient received one unit of PRBCs on 08/20/2011 which was started at 1700 and completed at 2000.

The "PATIENT AND UNIT VERIFICATION" section on the form listed the following "Order to transfuse is present and matches the component being transfused...Properly completed Informed Consent is in patient record AND Refusal to Permit Transfusion is not in patient record...Name & hospital number on recipient's wrist band matches the Blood Component Tag and the Blood Transfusion Record...Donor number on this Blood Transfusion Record matches Unit Number on Component and Blood Component Tag." Each of the listed items were preceded by a checkbox. All of the checkboxes were blank. The form further reflected "Identification verified and blood checked" followed by 2 signatures dated 08/20/2011 at 1650 and 1655. None of the documentation reflected how the patient's identification was verified or the blood was checked in accordance with the hospital's policy.

6. Patient record #10 was reviewed and contained a form titled "Blood Transfusion Record 1: Cellular Products." The form reflected the patient received one unit of PRBCs on 8/06/2011 which was started at 1000. The record reflected vital signs were completed at 1020. The blood transfusion and vital signs were completed at 1330, 3 hours and 10 minutes later.
The area on the form which reflected "Reaction observed? Yes/No" was not marked.

Review of the record lacked documentation that specified whether or not the patient had a reaction to the blood transfusion. The record lacked documentation that the patient was observed hourly as directed by the hospital's policy.

These findings were reviewed with the hospital's Center for Healthcare Improvement Director on 12/08/2011 at 1300.

Based on interview and review of medical staff rules and regulations and the review of medical records, it was determined that in 10 of 29 medical records (medical records #s 1, 4, 6, 7, 8, 23, 24, 26, 27, and 28) the hospital failed to ensure that all orders were dated, timed, and authenticated promptly by the ordering practitioner.

Findings include:

1. An interview with the Director of Center for Healthcare Improvement on 12/09/2011 at 1010 hours, reflected a problem with the current electronic medical record regarding the process of entering physician orders. When the orders were entered as "V" (verbal) or "T" (telephone) orders, the electronic medical system would notify the physician to authenticate the order. When orders were entered as "W" (written orders) the physician would not be electronically reminded to authenticate the order. Several medical records reflected some orders were entered as written orders.

2. Review of the "Sacred Heart Medical Center Medical Staff Services Rules, Regulations," Section 5 Orders...D.2. Verbal orders shall be signed, dated, and timed by the person taking the order, along with the name of the practitioner who dictates the order. Verbal orders shall be signed by the ordering practitioner or his alternate within 48 hours."

3. Record #1 - This patient was hospitalized from 10/25/2011 through 10/26/2011. This medical record contained 1 verbal order that was not authenticated. There were 4 orders that were not dated and/or timed per regulation.

Record #4- This patient was hospitalized from 11/03/2011 through 11/09/2011. This medical record contained 4 verbal orders that were not authenticated.

Record #6 - This patient was hospitalized on 6/30/2011. This medical record contained 2 orders that were not dated and/or timed per regulation.

Record #7 - This patient was hospitalized on 08/05/2011. There were 2 orders that were not timed per regulation.

Record #8 - This patient was hospitalized on 06/09/2011. This medical record contained 1 physician order and one "Blood or Blood Product Consent" form that were not timed per regulation.

Record #23 - This patient was medically screened and treated in the Emergency Department on 11/22/2011. The dictated medical record was not authenticated promptly per this regulation.

Record #24 - This patient was medically screened and treated in the Emergency Department on 11/24/2011. The dictated medical record was not authenticated promptly per this regulation.

Record #26 - The patient was hospitalized from 10/08/2011 through 10/11/2011. This medical record contained 6 verbal orders that were not authenticated. Three orders were not dated and/or timed.

Record #27 - The patient was hospitalized from 11/17/2011 through 11/18/2011. This medical record contained a verbal order that was not authenticated.

Record #28 - This patient was hospitalized from 10/01/2011 through 10/05/2011. This patient medical record contained 4 orders that were not timed.

.

Based on observation, interview, the review of documentation and policy and procedure review, it was determined that the hospital failed to ensure that emergency medication carts were maintained in accordance with its policies and procedures to ensure the integrity of the contents of the carts and the security of medications.

Findings include:

1. During a tour of the hospital's outpatient rehabilitation department on 12/09/2011 at 1330 with the Director of Rehabilitation Services, an emergency code cart and a corresponding "CRASH CART CHECKLIST" were observed. The checklist had columns which identified items on the cart that were to be checked and reflected "Date...Break Away Lock#...Cart Outdate Checked...Defib Check, See Job Aid...Zoll R Only Battery Check...1 set, Unopened Defib Pad on Cart...02 Tank PSI Level...Intubation Box...Resuscitation Bag...Signature & EMR #." Those observations revealed that the number on the plastic breakaway "lock" on the cart did not match the "lock" number recorded on the checklist. The "lock" number attached to the cart was observed to be 0116628. The "CRASH CART CHECKLIST" reflected a "Break Away Lock #" of 0116694 for 12/01/2011, 12/02/2011, 12/05/2011, 12/06/2011, 12/07/2011, 12/08/2011 and 12/09/2011.

A large wall mounted diagram was observed above the emergency cart. The diagram included pictures of the inside contents of the cart. During an interview with the Director of Rehabilitation Services on 12/09/2011 at 1255, he/she said the diagram on the wall had been outdated "for years." The director pointed out a list attached to the emergency cart and said that list was reflective of the contents of the cart, but was not the same as the wall mounted diagram.

During an interview with the Center for Healthcare Improvement Director on 12/09/2011 at 1430, he/she was informed of the emergency cart findings and the hospital's emergency cart policy and procedure was requested.

A policy titled "Crash Cart Maintenance, Location & Exchange-University District," dated as effective 08/29/2011 was received and reviewed. The policy and procedure required that "Departments that stock crash carts with medications and supplies shall maintain a checklist to verify that all items have been stocked as indicated...Every day during hours of operation the Crash Cart Checklist will be completed by a designated unit staff member for each crash cart located on the unit...The Crash Cart Checklist includes verifying the following items...Breakaway locks are present on the front of the crash cart doors enclosing the drugs and supplies and on the intubation box. Checking the crash cart includes checking that the locks are intact and writing the lock number from the front of the cart on the Daily Crash Cart Checklist. If the lock number is different than the previous number listed or if a lock is broken, call Materials Management to have the cart traded out."

The emergency cart documentation system required by policy and procedure had not been implemented. The emergency cart "lock" number did not match the emergency cart checklist and therefore the integrity and security of the medications in that cart was not assured. No further information was received for the duration of the survey which ended on 12/09/2011 at 1600



.

Based on staff interview and policy review, it was determined that the hospital failed to reassess its discharge planning process on an on-going basis as required.

1. An interview was conducted with the Interim Director of Case Management on 12/08/2011 at 1700. He/she identified that the hospital had a behavioral health unit with challenging discharge planning needs. He/she further revealed that the discharge planning staff had formulated a formalized "difficult discharge" process to address those challenges. The Interim Director was asked if the hospital reassesses its discharge planning process on an on-going basis and he/she said "No." He/she further revealed that the hospital's discharge planning process was not integrated into the quality assessment and performance improvement program.

2. The policy titled "Quality Assurance and Performance Improvement Plan" subtitled "Medical Social Work Plan," dated as effective 09/16/2011 was received and reviewed. The policy directed "Medical Social Work staff will participate in identifying appropriate quality assurance and improvement activities, gathering data and serving on interdisciplinary quality improvement teams...Aspects of care identified for monitoring and action will be based on...The frequency with which the service is provided (high volume)...The degree to which problems have arisen in the provision of service (problem prone)...The following are examples of aspects of care we typically monitor...Discharge planning assessment (high volume)..."