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Based on interview and record review, the hospital failed to provide a letter of response to 1 of 4 patients (Patient 5) who filed a complaint in 2017, thereby not adhering to their policy.

Findings included:

Patient #5 was admitted to the Emergency Department (ED) on 10/13/17 for diarrhea and altered mental status. On 10/14/17 the family filed a grievance. The hospital did not proved a final response letter to Patient #5's family's grievance.

In an interview with Personnel #7 on 02/26/18 at 0950 Personnel #7 was informed of the above findings and confirmed that a final written response was not sent to Patient #5's family.

The Complaints/ Grievances for Patients, Family and/or Visitors Policy 7 dated 06/22/90 and revised 06/21/16 reflected..."Page 2 7. Grievances should be responded to in writing and substantively address the areas of concern. Responses should include investigative methods used, findings and actions taken..."

Based on interview and record review, the hospital's registered nurse (RN) did not supervise and evaluate the nursing care for 4 out of 10 Patients (Patient #5, #6 , #7, and #10) , in that the RN did not promptly reassess the patient (patient # 6 and patient #7) after administering medications on 10/13/17 and 02/25/18. The RN did not reassess patient #5 after elopement from the ED and returning via EMS on 10/13/17, and the RN did not reassess patient #10 every shift while being held in the ED for a psychiatric evaluation for over 34 hours.

Findings Included:

Patient #5 was admitted to the ED on 10/13/17 for diarrhea, dementia, and altered mental status. The patient eloped from the ED at 1938 and was found wandering in the street by passersby. Patient #5 was returned to the ED on 10/13/17 at 2050 via EMS (Emergency Medical Services). The nurse failed to reassess patient #5 on her return to the ED.

Patient # 6 was admitted to the Emergency Department (ED) on 10/13/17 for symptomatic anemia.
The ED record evidenced Tylenol 650mg oral administered on 10/13/17 and GI Cocktail 50ml oral administered at 1202. The ED Flowsheet reflected a pain reassessment at 1352 1 hour and 50 minutes later.

Patient #7 was admitted to the ED on 10/13/17 for Fatigue.
The ED record evidenced Patient #7 was placed on a Levophed IV drip 0.1mcg/kg/min at 1130. The vital signs were taken at 1143 and again at 1242 59 minutes after the first set of vital signs were taken.

Patient #10 was admitted to the ED on 02/25/18 with convulsions related to drug ingestion.
The ED record evidenced Tylenol 1000mg oral administered on 02/25/18 at 0440. Patient #10's pain level was reassessed at 0759, 3 hours and 19 minutes later.
Patient #10 was admitted to the ED on 02/25/18 at 0356 as of 02/26/18 at 1200 Patient #10 was still a patient in the ED 32 hours and 4 minutes later. Patient #10 had an initial nursing assessment upon admission to the ED with no other reassessment documented.

In an interview on 02/26/18 ending at 1305 Personnel #6 was informed of the above findings and confirmed the findings. Personnel #6 stated the time frame for following up on pain medication administration is 1 hour and the vital signs should have been taken every 15 minutes when a patient is on a Levophed drip.

The Pain Assessment and Management policy dated 10/17/01 and revised 08/02/17 reflected on page 1 "Guidelines: 2. After each pain management intervention, reassessment should not exceed 60 minutes."
The Adult Intravenous Medication Guidelines approved by the Pharmacy and Therapeutics and Medical Executive Committees April 2016 reflected on pate 61."ICU Vitals Q15 min. x4 (every 15 minutes times 4)..."
The Patient Assessment Reassessment policy dated 01/17/06 and revised 09/0917 reflected on page 3 "Nursing Departments: 2. Complete a re-assessment...1. Minimum of every shift..."

Based on interview and record review, the hospital failed to follow the approved medical staff policies and procedures in that 1 of 10 patients (Patient #6) received a blood transfusion and there was no evidence of vital signs being taken when the transfusion completed.

Findings Included:

Patient #6's electronic record contained documentation of a transfusion of Leukoreduced RBC (red blood cells) started at 1333 and completed at 1530. The last documented vital signs were at 1352.

During electronic record review and interview on 02/26/18 at 1100 Personnel #3 was asked if Patient #6 had vital signs taken at the end of the blood transfusion. Personnel #3 stated "no, there were no vital signs taken at the completion of the transfusion."

The Blood/Blood Components Transfusion Policy dated 03/15/95 and revised 12/15/15 page 1 reflected"5. Vital signs must be taken and documented at the initiation of the transfusion, after the first 15 minutes of the transfusion, and upon completion of the transfusion."