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Based on record review and staff interviews, the Hospital failed to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by failing to investigate a patient grievance completely and in a timely manner in accordance with the hospital policy for 1 (#2) of 2 (#2, #6) sampled patients reviewed for grievances out of a total sample of 7 (#1-#7).

Findings:

Review of the Hospital policy titled, Patient Complaints/Grievances, Policy No. RI-110, revealed in part the following: Timely, reasonable, and effective response to complaints or grievances increases patient satisfaction and promotes the resolution of conflicts in a non-adversarial fashion....Upon receipt of a grievance, the person receiving the grievance shall document the grievance in the online Occurrence Reporting system. Documentation of all follow-up to grievances shall be maintained in the on-line Occurrence Reporting System. Once the complaint has become a grievance the information will be forwarded to appropriate department director(s) for investigation. The patient, and/or their representative, will be sent a letter of acknowledgement via U.S. Postal Service, informing them that a grievance has been opened on their behalf. If a resolution of the grievance cannot be achieved within seven (7) days, a letter will be sent to the patient and/or their representative informing them that the investigation is still underway, and that a letter of resolution will be sent to them within the next twenty-one (21) days....

Patient #2
Review of the Hospital's on-line Occurrence Reporting System revealed Patient #2 submitted a grievance by telephone on 08/02/17 regarding the emergency department. Review of the Complaint Description revealed the following: Patient called Patient Experience Coordinator to voice the following concerns: Patient states that she presented to the ED after trying to "commit suicide". Patient states that S5Physician refused to admit her or assist her in finding a mental health facility because she was "a danger to herself." Patient states that she had wounds from "jumping out of a car on the interstate" and that the doctor told her that someone would come in and clean the wounds but this never happened. Patient states that she told the doctor that she was "afraid of what she might do to herself" and he basically ignored her. Patient states that the nurse that came into her room to put a splint on her foot and that she was pleading with the nurse to stop because of the "horrible pain" and the nurse replied, "I have to do it like this so keep still". Patient states that it seemed that no one cared about her as a person. Patient states that she thinks she should have had a psych evaluation but she did not receive one.
The grievance also revealed the number of follow investigations was 2 and all follow ups were completed. Further review of the grievance revealed the investigators were S2Interim DQ/RM and S13Quality. The investigation documented was as follows: Case reviewed by S13Quality. S13Quality followed up with patient. Recommendations were documented as: Reiterate with ED staff importance of listening to patient concerns, and following suicide risk assessment policy.

In an interview on 09/18/17 at 2:48 p.m., S13Quality stated S6MDED did the peer review on this case. S13Qualtiy Charlotte confirmed that she had spoken to patient and she asked the patient if she was suicidal and she stated she was not and she did not need any further assistance. She stated this was all that was discussed in the phone call. Stated she only looked at the grievance from a physician standpoint. S13Qualtiy stated usually the grievance would be forwarded to the nurse manager for follow up but the ED manager left around this time. S2Interim DQ/RM, also present for the interview, stated they called the patient to ensure she was no longer suicidal or needed services. S2Interim DQ/RM confirmed no investigation of the wound care or nursing issues had been done yet and the nursing staff have not been interviewed. She stated a 7 day letter has been sent and a peer review was done. S2Interim DQ/RM confirmed the grievance had not been promptly resolved.

Review of the letters provided by S14PtEC as the letters sent to Patient #2 revealed the following:
08/02/17 (date grievance received by hospital) - Letter sent to Patient #2: The concerns you expressed regarding the care you received at Slidell Memorial Hospital have been referred to the appropriate management staff...Your concerns are currently being reviewed, and we anticipated providing a verbal or written response to you within the next 21 business days .....Letter done by S14PtEC.

09/01/17 (30 days after grievance received by hospital) - Letter sent to Patient #2: We remain in the process of investigating the concerns regarding the care you received at Slidell Memorial Hospital. It is our goal to respond to patient and family concerns received by the hospital within 21 business days. Our review includes interviews with the staff involved in your care, and a review of your medical record. Unfortunately, we have not as yet completed these interviews ....Letter done by S14PtEC.

In an interview on 09/18/17 at 3:03 p.m., S14PtEC confirmed the above letters were mailed to Patient #2. S14PtEC stated the investigation was still pending. S2Interim DQ/RM also present for the interview stated she had to get with the staff and do interviews. S2Interim DQ/RM confirmed the grievance had not been resolved within 21 days and the second letter was not sent to the patient within 7 days as directed in the hospital's policy.

Based on record review and interview, the medical staff failed to ensure its accountability to the governing body for the quality of medical care provided to patients. This deficient practice was evidenced by failure of the physician to order wound care for an emergency department patient with multiple abrasions for 1 (#2) of 3 (#1, #2, #4) sampled ED patients reviewed with wounds out of a total sample of 7 (#1-#7) patients.

Findings:

Review of the Medical Staff Bylaws, Rules & Regulations dated 08/20/14, provided by S2Interim QD/RM revealed in part the following: Emergency Services: An emergency services medical record shall be kept for every patient....The record shall include: Diagnostic and therapeutic orders....Clinical observations and assessments, including results of treatments....

Patient #2
On 09/18/17 at 2:30 p.m. the electronic medical record for Patient #2 was reviewed with S3RN (Interim ED Head Team Member). Review of the record revealed the patient was a 29 year old who presented to the ED on 07/14/17 at 5:46 a.m. with a complaint of, "Jumped out of car at approx. 20 MPH." Review of the nursing assessment of the patient's skin dated/timed 07/14/17 at 6:20 a.m. revealed the following: Abrasion sustained to buttocks, right hand, left hand, right arm, left arm, right leg and left leg is bleeding, imbedded with road debris, was sustained less than 30 minutes ago.
Further review of the nurse documentation revealed no documentation of any wound care provided to the patient's abrasions. The record revealed the patient was discharged to home at 9:25 a.m.

Review of the physician progress note documented by S5Physician revealed the following: 8:31 a.m. ED Course-The patient's abrasions will be cleansed and dressed and she will also have a posterior splint placed on the left lower extremity along with the use of crutches.

Review of the physician orders revealed no documented evidence of any orders for wound care for the patient's multiple abrasions.

In an interview on 09/18/17 at 2:30 p.m., S3RN stated normally there is a physician's order to clean wounds. S3RN confirmed he did not see an order in the patient's record. After review of nurse assessments, S3RN confirmed there was no documentation that the abrasions were cleaned and dressed in the ED. S3RN confirmed nursing assessment indicated the abrasions were imbedded with road debris and confirmed the patient's wounds should have been cleaned.

In an interview on 09/19/17 at 9:40 a.m., S9RN reviewed the ER record for Patient #2 and confirmed he did the assessment on the patient when the patient was placed in a room. S9RN stated he was working the night shift and this assessment was done just before shift change at 7:30. S9RN indicated that when he documented road debris was imbedded in the wounds he was indicating rocks were in the wounds. S9RN confirmed he did not remember doing any wound care to the abrasions.

In an interview on 09/19/17 at 10:04 a.m., S11ER Tech confirmed she had applied the left lower extremity splint to the patient's leg and stated she had wiped some scuff marks off the toes with Normal Saline and 2X2 gauze. S11ER Tech denied doing any other wound care to the patient.

In an interview on 09/19/17 at 10:23 a.m., S10RN confirmed she came on duty at 8:00 a.m. and assumed care of Patient #2. S10RN stated she went to room to discharge the patient and she noticed the splint was a little too snug. S10RN stated she and the ER Tech unwrapped the splint and reapplied it. S10RN stated wound care wound have been done before the splint was applied and there was usually an order for it. S10RN stated the ER tech would have cleaned the wounds. S10RN stated anybody can do the wound care but generally the techs do it. S10RN stated, "I am almost positive some wound care was done but it wasn't done by me." S10RN stated nursing does not see what the physician documents in the ED Course and they provide treatments that are in the orders. S10RN nurses can also enter verbal orders for treatments.

In an interview on 09/19/17 at 11:10 a.m., S5Physician reviewed the patient's record and stated he did not remember the patient. When asked about the wound care for the abrasions he stated he would assume the nurse cleaned the wounds or obtained a verbal order to clean wounds. When informed the record did not include orders for wound care or documentation that wound care was done, he stated the nurse would have obtained a verbal order.

Based on record review and staff interview, the Hospital failed to ensure the Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by failing to ensure an emergency department patient who sustained multiple abrasions was provided wound care as evidenced by failing to obtain physician orders for wound care and failing to document any wound care provided to the patient for 1 (#2) of 3 (#1, #2, #4) sampled emergency department patients with wounds out of a total sample of 7 (#1-#7).

Findings:

Patient #2
On 09/18/17 at 2:30 p.m. the electronic medical record for Patient #2 was reviewed with S3RN (Interim ED Head Team Member). Review of the record revealed the patient was a 29 year old who presented to the ED on 07/14/17 at 5:46 a.m. with a complaint of, "Jumped out of car at approx. 20 MPH." Review of the nursing assessment of the patient's skin dated/timed 07/14/17 at 6:20 a.m. revealed the following: Abrasion sustained to buttocks, right hand, left hand, right arm, left arm, right leg and left leg is bleeding, imbedded with road debris, was sustained less than 30 minutes ago.
Further review of the nurse documentation revealed no documentation of any wound care provided to the patient's abrasions. The record revealed the patient was discharged to home at 9:25 a.m.

Review of the physician progress note documented by S5Physician revealed the following: 8:31 a.m. ED Course-The patient's abrasions will be cleansed and dressed and she will also have a posterior splint placed on the left lower extremity along with the use of crutches.

Review of the physician orders revealed no documented evidence of any orders for wound care for the patient's multiple abrasions.

In an interview on 09/18/17 at 2:30 p.m., S3RN stated normally there is a physician's order to clean wounds. S3RN confirmed he did not see an order in the patient's record. After review of nurse assessments, S3RN confirmed there was no documentation that the abrasions were cleaned and dressed in the ED. S3RN confirmed nursing assessment indicated the abrasions were imbedded with road debris and confirmed the patient's wounds should have been cleaned.

In an interview on 09/19/17 at 9:40 a.m., S9RN reviewed the ER record for Patient #2 and confirmed he did the assessment on the patient when the patient was placed in a room. S9RN stated he was working the night shift and this assessment was done just before shift change at 7:30. S9RN indicated that when he documented road debris was imbedded in the wounds he was indicating rocks were in the wounds. S9RN confirmed he did not remember doing any wound care to the abrasions.

In an interview on 09/19/17 at 10:04 a.m., S11ER Tech confirmed she had applied the left lower extremity splint to the patient's leg and stated she had wiped some scuff marks off the toes with Normal Saline and 2X2 gauze. S11ER Tech denied doing any other wound care to the patient.

In an interview on 09/19/17 at 10:23 a.m., S10RN confirmed she came on duty at 8:00 a.m. and assumed care of Patient #2. S10RN stated she went to room to discharge the patient and she noticed the splint was a little too snug. S10RN stated she and the ER Tech unwrapped the spint and reapplied it. S10RN stated wound care wound have been done before the splint was applied and there was usually an order for it. S10RN stated the ER tech would have cleaned the wounds. S10RN stated anybody can do the wound care but generally the techs do it. S10RN stated, "I am almost positive some wound care was done but it wasn't done by me." S10RN stated nursing does not see what the physician documents in the ED course and they provide treatments that are in the orders. S10RN nurses can also enter verbal orders for treatments.

In an interview on 09/19/17 at 11:10 a.m., S5Physician reviewed the patient's record and stated he did not remember the patient. When asked about the wound care for the abrasions he stated he would assume the nurse cleaned the wounds or obtained a verbal order to clean wounds. Informed the record did not include orders for wound care or documentation that wound care was done, he stated the nurse would have obtained a verbal order.

Based on record reviews and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the nursing staff as evidenced by failure to have documented evidence of Crisis Prevention Intervention certification within 90 days of hire for 1 of 1 (S11ERTech) ER Techs reviewed out of a total of 5 (S8RN, S9RN, S10RN, S11ERTech, S12RN) emergency department personnel records reviewed for competency in Crisis Prevention Intervention.

Findings:

Review of the personnel record for S11ERTech revealed a date of hire of 04/17/17 as an emergency room technician.
Review of the Job Description signed by S11ERTech on 04/13/17 revealed all unit specific skills and competencies would be completed prior to the end of the 90 day evaluation.
Review of the Emergency Department Tech-Orientation Skills Assessment/Competency Checklist dated 04/17/17 revealed CPI certification was to be done within 90 day of hire.
Review of the personnel record revealed no documented evidence that CPI certification had been completed for S11ERTech.

In an interview on 09/19/17 at 2:41 p.m., S2Interim DQ/RM confirmed all competencies should be completed by the end of 90 days. S2Interim DQ/RM confirmed there was no documentation in the personnel record that indicated S11ERTech had completed the CPI certification. S1Interim DQ/RM also stated she had reviewed the transcripts for the online training completed by S11ERTEch and she did not see CPI training. S2Interim DQ/RM confirmed the CPI should have been done within the 90 day probationary period as indicated in the job description and competency assessment. S2Interim DQ/RM confirmed the ER techs are at times assigned to monitor PEC/Psych patients.

In an interview on 09/19/17 at 2:50 p.m., S4RN, Lead Administrative Supervisor stated S11ERTech has not had CPI and stated it was an error in human resources as she was not flagged as needing it when she was hired.