HospitalInspections.org

Based on document review, policy and procedure review and interview, the patient relations department and the grievance committee failed to implement its policy and procedure ensuring an effective grievance process for one grievance reviewed, related to patient N1.

Findings:
1. At 12:15 PM on 5/20/10, review of the policy and procedure "Patient/Visitor Complaints", "File No: ADM-RI-3-P" with a most recent review/revision date of 5/15/09, indicated:
a. on page two under section III., it read: "...The Patient Representative Department provides a service through which patients/families can seek solutions to problems concerning care or services and staff can refer patient issues,..."
b. on page 3 under section II. "Administration of Patient Grievances", it read: "A. Upon the Patient Representative Department's receipt of a Patient Grievance, Patient Representative personnel will make every effort to make initial contact with the patient/family within 24 business hours..."

2. At 2:25 PM on 5/19/10, review of patient/family complaints indicated:
a. The complaint documented as #10-317 was entered in the facility system by staff member NC after a call from the patient was left on the answering machine 3/3/10 complaining of:
A. Discharge from the hospital without having voided or having a bowel movement
B. long wait for service in the ED
C. rude unprofessional behavior of ED staff
D. ED nurse gave IV medication that patient was allergic to and caused to vomit
b. per documentation, these allegations were referred on to staff member NE for follow up
c. notes added on line, by staff member NE on 3/25/10 indicated: staff member NE had met with the patient (N1) while they were in the ED on 3/3/10 and felt the issues were addressed at that time (no further contact or follow up was made by staff member NE)

3. At 2:10 PM on 5/20/10, interview with staff member NC indicated:
a. a family member of the patient called to voice a complaint and was told that the patient, themself, needed to file the complaint, "due to HIPAA", and that no information could be given to the caller (this caller was not the "patient's representative", but was a "concerned family member"). The patient then called in and a complaint was logged in by this staff member on 3/10/10
b. a letter was sent on 3/17/10 to the patient indicating an investigation would be done
c. this staff member was unclear why some of the allegations by the complainant/patient related to issues of patient care/concern (discharge from the hospital without having voided or having a bowel movement) while on the 7 north nursing unit were not documented as being followed up on
d. the patient relations department isn't following the policy related to initial contact with a complainant within 24 hours, instead a letter is sent stating that an investigation is taking place
e. due to privacy issues, complaints will only be taken by patients themselves

4. At 3:00 PM on 5/20/10, interview with staff member NA indicated:
a. the current complaint policy indicates that complainants will be contacted within "24 business hours" and if the process has been changed, the policy should have also been updated/changed
b. it was unknown by this staff person that only patients could file a complaint with the facility--it has always been facility policy that anyone could file a complaint/concern on behalf of a patient--confidential patient/health information does not have to be shared to follow up on a complaint by another person
c. it does not appear that all of allegations listed in the patient's complaint were addressed or investigated by nursing staff or the patient relations department (discharge from the hospital without having voided or having a bowel movement)
d. documentation of thorough follow up to complaint issues/concerns is lacking for complaint # 10-317

Based on patient medical record review, policy and procedure review and interview, the nurse executive failed to ensure the policy related to pain documentation and reassessment was implemented for 4 of 6 patients (N1, N3, N4 and N5).

Findings:
1. At 11:45 AM on 5/19/10, review of the policy and procedure "NSP-81-P"--"Pain Assessment and Management in Adults and Older Adults" with a last reviewed/revised date of 11/6/09, indicated:
a. under section IV., "Ongoing Pain Assessment--Pain is considered the "5th Vital Sign" and will be assessed and documented when vital signs are obtained...C. Re-assessment and documentation of post-intervention effectiveness includes the following:...2. Re-assessment occurs within 30 minutes of parenteral administration of analgesic medication. 3. Re-assessment occurs within 60 minutes of oral administration of analgesic medication..."

2. Apt. N1:
A. was admitted to the ED on 3/1/10 with a pain level documented at "10" at 8:59 AM. Zofran 4 mg was given IV at 9:56 AM, Toradol 30 mg was given IV at 9:57 AM and Morphine 4 mg was given IV at 9:58 AM. At 11:24 AM, the patient went to CT and returned to the ED at 11:45 AM. At 12:47 PM the patient was taken to surgery. No pain level was documented after the admission level of 10 was noted. No discharge vital signs or pain level were documented by nursing staff on the "Emergency Department Nursing Treatments and Procedures" form when discharged/transferred to surgery.
B. was given Toradol 30 mg at 6:37 PM on 3/2/10 while on the 7 north nursing unit for post operative pain at a level of 5, but is lacking any follow up reassessment after the medication was given
C. was given Dilaudid at 3:47 AM on 3/2/10 for a pain level of 7, but is lacking any follow up reassessment after the medication was given

b. pt. N3 was seen in the ED on 3/3/10 with a pain level of "8" noted at 4:56 PM. Naprosyn was given at 5:50 PM. The patient was discharged at 7:25 PM with no further notation by nursing staff of a pain level after the admission documentation of a level of 8.

c. pt. N4 was admitted with a pain level of 7 (out of 10) and discharged with a pain level of 8. During the ED visit, pt. N4 was given Nubain, Toradol, Zofran, and Benadryl within a 1 hour and 8 minute time frame, but was lacking any documentation of pain level between the start time of the first medication 5:46 PM and the discharge time at 6:57 PM, when the pain level is noted as being "8/10"

d. pt. N5 was admitted with a pain level of 8 (out of 10) and discharged lacking documentation of a pain level at the time of discharge. During the ED visit, pt. N5 was given DHE (dihydroergotamine), Toradol, Phenergan and Morphine within a 45 minute time frame with no documentation of pain level any time during the patient's 1 hour and 57 minute stay in the ED, except for the admission level of 8.

3. Interview with staff member NA at 3:00 PM on 5/20/10 indicated:
a. no follow up reassessment was performed for patient N1, either in the ED on 3/1/10, or when an in patient on 7 North post operatively as noted in 2. a. above
b. ED staff are not reassessing and documenting pain levels after medications are being given in the ED as per facility policy
c. ED nursing staff are to be documenting a discharge pain level, per facility protocol, "this is not a policy, but a standard of practice", and this is lacking for patients N1, N3, and N5
d. pt. N4 should not have been discharged with a pain level higher than that documented on admission to the ED