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Based on record review and staff interview, the facility failed to implement a program to capture, investigate, and analyze grievances for 4 (Patients #11, #16, #17, and #18) of 8 patients reviewed.

The findings included:

Four patients (Patients #11, #16, #17 and #18) notified the Agency for Health Care Administration (AHCA) of grievances with Gulf Coast Medical Center. All 4 complainants stated they spoke to staff, including management, without resolution of follow-up. Only 1 of the grievances reported to AHCA (Patient #11) was found on the facility's grievance log. Patients #16, #17, and #18, stated they spoke with management staff, but no grievance was documented and the patients are not listed on the grievance log. Patient #11's grievance, investigated by hospital staff, was not resolved to the complainant's satisfaction as reported in the complaint to AHCA.

Four grievances found on the facility's grievance log with similar complaints, as those above reported to AHCA, were reviewed (Patients #12, #13, #14, and #15). Two of the four grievances(Patients #12 and #14) were validated by the facility and resolved.

Patient #13 had a problem with receiving medication as he was transferred from 1 hospital in the system to Gulf Coast Medical Center (GCMC). The patient's record documents the discharge planner notified guest services of the mix-up; however, there is no documented follow through to resolution.

Patient #15 stated her ID was not returned to her. The staff member investigating the grievance documented the ID was not requested by the facility; therefore, the facility did not have possession. A review of the electronic record shows the ID was scanned into the HI system on the date of admission. There was inadequate investigation and no timely resolution of the grievance.

A review of the Grievance Policy reveals the facility staff are instructed on how to interact with the complainant. There is no protocol or procedure for investigating the grievance. There is no standardized methodology for investigation. A review of the investigations finds there is no documented interviews of personnel involved. The guest services department tallies the grievances but does not analyze the root cause of the concerns in the complaint. The facility does not follow-up on changes implemented and the facility has vague goals for the reduction of grievances.
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Based on interview and record review, the facility failed to ensure the primary care physicians were notified and physician treatment ordered, received, and started for 3 (Patients #10, #20, and #21) of 29 patients identified by the facility with a pressure ulcer.
The findings included:
On 6/7/16, review of the Wound and Pressure Ulcer Assessment and Treatment Policy and Procedure #904 state a comprehensive skin assessment of all patients must be completed within 24 hours by a Registered Nurse (RN). Wound findings are to be documented in the medical records and an Interdisciplinary Plan of Care (IPOC) for pressure ulcers. Stages 1-4 will be initiated for the appropriate pressure ulcer stage within 24 hours. The primary care physician must be called for wound care and dressing change orders if none available upon admission.
1. On 6/7/16, review of Patient #10's medical records revealed she was admitted to the 4 West Unit of the hospital on 6/2/16.
A nursing progress note dated 6/2/16 at 1722, the nurse wrote redness to the coccyx with a Stage II, 1.0 X 1.5. The nurse applied a mepilex dressing to the Stage II pressure ulcer. On 6/3/16 at 8:45 a.m., the nurse wrote the dressing to the coccyx is clean and dry. On 6/4/16 at 9:36 p.m., and 6/5/16 at 9:00 p.m., the nurse wrote pressure ulcer is open to air and is scabbed over. On 6/6/16 at 1958, the nurse wrote dressing applied to pressure ulcer to coccyx. There is no documentation the primary care physician was notified on 6/2/16, of Patient #10 having a Stage II pressure ulcer to her coccyx and on 6/4/16, when the Stage II pressure ulcer became unstageable due to the scab.
On 6/7/16 at 2:00 p.m., in an interview, the Stroke Unit Supervisor (SUS), after reviewing Patient #10's medical records, she confirmed Patient #10 was admitted on 6/2/16, with a Stage II pressure ulcer to her coccyx which developed into a unstageable pressure ulcer on 6/4/16. She confirmed there is no documentation in the medical record documenting the primary care physician was notified upon admission of the Stage II pressure ulcer or the unstageable pressure ulcer on 6/4/16. The nursing staff did not call the physician for a treatment order for the pressure ulcer to the coccyx. She also confirmed the nursing staff did not initiate an IPOC for a pressure ulcer within 24 hours as required by their policy and procedure for pressure ulcers.
2. On 6/7/16, a review of Patient #20's medical records revealed he was admitted to the facility on 5/31/16 and sent to the floor, 4 West Unit on 6/1/16. The floor nurse wrote on 6/1/16 at 2:06 a.m., noted multiple bruising and a Stage 1 non-blanchable redness to the sacrum/coccyx area. There is no documentation the primary care physician was notified of the Stage 1 pressure ulcer to the sacrum/coccyx area or an IPOC was started within 24 hours of identifying the pressure ulcer.
On 6/7/16 at 3:15 p.m., in an interview, the Director of 4 West Nursing Unit, after she reviewed Patient #20's medical record, she confirmed the primary care physician was not notified of the pressure ulcer to the sacrum/coccyx area, including the initiation of an IPOC for pressure ulcers within 24 hours as required per their policy and procedure for pressure ulcer assessment.
3. On 6/8/16, a review of Patient #21's medical records revealed he was admitted to the facility on 5/28/16, to the Intensive Care Unit (ICU). The ICU nurse assessment progress note dated 5/28/16 at 9:00 a.m., noted bruising to left arm, excoriation and rash to the middle of the back, left heel unstageable pressure ulcer, Stage II pressure ulcer to the coccyx, and a deep tissue injury to the coccyx. There is no documentation the primary care physician was notified upon admission of Patient #21's pressure ulcer within 24 hours.
On 6/8/16 at 8:50 a.m., in an interview, SUS confirmed Patient #21's admission assessment dated 5/28/16, identified a left heel unstageable pressure ulcer, Stage II pressure ulcer to the coccyx, and a deep tissue injury to the coccyx. She said the IPOC for pressure ulcers was not initiated until 6/1/16, 4 days after the pressure ulcers were identified. She confirmed the primary care physician was not notified and the IPOC for pressure ulcers were not initiated as per their policy and procedures for pressure ulcers.
4. On 6/8/16 at 10:00 a.m., the Director of 4 West Nursing Unit, said she reviewed all the patients identified with pressure ulcers on her unit. She confirmed the nursing staff were not notifying the primary care physician and/or initiating the IPOC for pressure ulcers within 24 hours as required via the policy and procedures for pressure ulcers.
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Based on observation, interview, and record review, the facility failed to ensure essential equipment was clean, and free of an accumulation of mineral deposits. This has the potential to effect the health and safety of the patients.

The findings included:
On 6/6/16 at 10:15 a.m., a tour of the nourishment rooms revealed the following:
The East Wing has 3 nourishment rooms, an observation revealed all 3 nourishment rooms had stand-alone ice /water machines. All 3 machines were observed with an accumulation of calcium residue located on the black plastic slotted water drains. The stainless steel exterior of the ice machines had calcium stains, seams, and crevices, and on the exterior side had an accumulation of calcium seeping out of the crevices.
On 6/6/16 at 10:59 a.m., a tour of the West and South Wing nourishment rooms observed stand-alone ice machines with various degrees of calcium build-up on the exterior of the machines. This included 6 more ice machines, which totaled 9 machines in all.
On 6/10/16 at 10:00 a.m., toured the East Wing nourishment rooms with the Director of Dietary Services (DFS) who agreed there is an accumulation of calcium on the ice machines. DFS said the filters on the machine are changed at least yearly, or more often if needed. DFS said the calcium does build up on the machines all the time, and the machines are usually cleaned weekly. The DFS said she would be addressing the issue of the calcium buildup with the Director of Plans and Operation (DPO).
On 6/10/16 at 11:00 a.m., the DPO said the filters of the ice machine are usually changed more often than yearly, due to the high concentration of calcium in the city water. The DPO said the facility does not have a water softener system in place for the cold water in the facility because it would be too costly. The DPO said some of the parts on the ice machine are plastic and very porous, and need to be replaced. The replacement parts are expensive, and are only changed when they are really bad. He agreed the ice machines should be part of a preventitve maintance program.
On 6/11/16 at 11:20 a.m., a phone conversation was conducted with the DPO about water quality testing. The DPO said the facility does not test the quality of the water.
A review of the facility's approved policy titled "Preventive Work Order" states: "Check water filter and change if need or annually. Check date on filter for verification of date of last change out." The policy does not address the prevention of large calcium deposits in and on the ice machines.
Refer to manufacturer's service manual for specific tasks not included in the procedures provided in this work order.
"1. Clean water side of systems.
2. Clean compressor compartment of machine.
3. Check safety's.
4. Check for refrigerant leaks and proper frost line, which should frost out of the accumulator no closer than 8-12 inches from compressor."

Based on record review and staff interview, the facility failed to implement a program to capture, investigate, and analyze grievances for 4 (Patients #11, #16, #17, and #18) of 8 patients reviewed.

The findings included:

Four patients (Patients #11, #16, #17 and #18) notified the Agency for Health Care Administration (AHCA) of grievances with Gulf Coast Medical Center. All 4 complainants stated they spoke to staff, including management, without resolution of follow-up. Only 1 of the grievances reported to AHCA (Patient #11) was found on the facility's grievance log. Patients #16, #17, and #18, stated they spoke with management staff, but no grievance was documented and the patients are not listed on the grievance log. Patient #11's grievance, investigated by hospital staff, was not resolved to the complainant's satisfaction as reported in the complaint to AHCA.

Four grievances found on the facility's grievance log with similar complaints, as those above reported to AHCA, were reviewed (Patients #12, #13, #14, and #15). Two of the four grievances(Patients #12 and #14) were validated by the facility and resolved.

Patient #13 had a problem with receiving medication as he was transferred from 1 hospital in the system to Gulf Coast Medical Center (GCMC). The patient's record documents the discharge planner notified guest services of the mix-up; however, there is no documented follow through to resolution.

Patient #15 stated her ID was not returned to her. The staff member investigating the grievance documented the ID was not requested by the facility; therefore, the facility did not have possession. A review of the electronic record shows the ID was scanned into the HI system on the date of admission. There was inadequate investigation and no timely resolution of the grievance.

A review of the Grievance Policy reveals the facility staff are instructed on how to interact with the complainant. There is no protocol or procedure for investigating the grievance. There is no standardized methodology for investigation. A review of the investigations finds there is no documented interviews of personnel involved. The guest services department tallies the grievances but does not analyze the root cause of the concerns in the complaint. The facility does not follow-up on changes implemented and the facility has vague goals for the reduction of grievances.
.

Based on interview and record review, the facility failed to ensure the primary care physicians were notified and physician treatment ordered, received, and started for 3 (Patients #10, #20, and #21) of 29 patients identified by the facility with a pressure ulcer.
The findings included:
On 6/7/16, review of the Wound and Pressure Ulcer Assessment and Treatment Policy and Procedure #904 state a comprehensive skin assessment of all patients must be completed within 24 hours by a Registered Nurse (RN). Wound findings are to be documented in the medical records and an Interdisciplinary Plan of Care (IPOC) for pressure ulcers. Stages 1-4 will be initiated for the appropriate pressure ulcer stage within 24 hours. The primary care physician must be called for wound care and dressing change orders if none available upon admission.
1. On 6/7/16, review of Patient #10's medical records revealed she was admitted to the 4 West Unit of the hospital on 6/2/16.
A nursing progress note dated 6/2/16 at 1722, the nurse wrote redness to the coccyx with a Stage II, 1.0 X 1.5. The nurse applied a mepilex dressing to the Stage II pressure ulcer. On 6/3/16 at 8:45 a.m., the nurse wrote the dressing to the coccyx is clean and dry. On 6/4/16 at 9:36 p.m., and 6/5/16 at 9:00 p.m., the nurse wrote pressure ulcer is open to air and is scabbed over. On 6/6/16 at 1958, the nurse wrote dressing applied to pressure ulcer to coccyx. There is no documentation the primary care physician was notified on 6/2/16, of Patient #10 having a Stage II pressure ulcer to her coccyx and on 6/4/16, when the Stage II pressure ulcer became unstageable due to the scab.
On 6/7/16 at 2:00 p.m., in an interview, the Stroke Unit Supervisor (SUS), after reviewing Patient #10's medical records, she confirmed Patient #10 was admitted on 6/2/16, with a Stage II pressure ulcer to her coccyx which developed into a unstageable pressure ulcer on 6/4/16. She confirmed there is no documentation in the medical record documenting the primary care physician was notified upon admission of the Stage II pressure ulcer or the unstageable pressure ulcer on 6/4/16. The nursing staff did not call the physician for a treatment order for the pressure ulcer to the coccyx. She also confirmed the nursing staff did not initiate an IPOC for a pressure ulcer within 24 hours as required by their policy and procedure for pressure ulcers.
2. On 6/7/16, a review of Patient #20's medical records revealed he was admitted to the facility on 5/31/16 and sent to the floor, 4 West Unit on 6/1/16. The floor nurse wrote on 6/1/16 at 2:06 a.m., noted multiple bruising and a Stage 1 non-blanchable redness to the sacrum/coccyx area. There is no documentation the primary care physician was notified of the Stage 1 pressure ulcer to the sacrum/coccyx area or an IPOC was started within 24 hours of identifying the pressure ulcer.
On 6/7/16 at 3:15 p.m., in an interview, the Director of 4 West Nursing Unit, after she reviewed Patient #20's medical record, she confirmed the primary care physician was not notified of the pressure ulcer to the sacrum/coccyx area, including the initiation of an IPOC for pressure ulcers within 24 hours as required per their policy and procedure for pressure ulcer assessment.
3. On 6/8/16, a review of Patient #21's medical records revealed he was admitted to the facility on 5/28/16, to the Intensive Care Unit (ICU). The ICU nurse assessment progress note dated 5/28/16 at 9:00 a.m., noted bruising to left arm, excoriation and rash to the middle of the back, left heel unstageable pressure ulcer, Stage II pressure ulcer to the coccyx, and a deep tissue injury to the coccyx. There is no documentation the primary care physician was notified upon admission of Patient #21's pressure ulcer within 24 hours.
On 6/8/16 at 8:50 a.m., in an interview, SUS confirmed Patient #21's admission assessment dated 5/28/16, identified a left heel unstageable pressure ulcer, Stage II pressure ulcer to the coccyx, and a deep tissue injury to the coccyx. She said the IPOC for pressure ulcers was not initiated until 6/1/16, 4 days after the pressure ulcers were identified. She confirmed the primary care physician was not notified and the IPOC for pressure ulcers were not initiated as per their policy and procedures for pressure ulcers.
4. On 6/8/16 at 10:00 a.m., the Director of 4 West Nursing Unit, said she reviewed all the patients identified with pressure ulcers on her unit. She confirmed the nursing staff were not notifying the primary care physician and/or initiating the IPOC for pressure ulcers within 24 hours as required via the policy and procedures for pressure ulcers.
.

Based on observation, interview, and record review, the facility failed to ensure essential equipment was clean, and free of an accumulation of mineral deposits. This has the potential to effect the health and safety of the patients.

The findings included:
On 6/6/16 at 10:15 a.m., a tour of the nourishment rooms revealed the following:
The East Wing has 3 nourishment rooms, an observation revealed all 3 nourishment rooms had stand-alone ice /water machines. All 3 machines were observed with an accumulation of calcium residue located on the black plastic slotted water drains. The stainless steel exterior of the ice machines had calcium stains, seams, and crevices, and on the exterior side had an accumulation of calcium seeping out of the crevices.
On 6/6/16 at 10:59 a.m., a tour of the West and South Wing nourishment rooms observed stand-alone ice machines with various degrees of calcium build-up on the exterior of the machines. This included 6 more ice machines, which totaled 9 machines in all.
On 6/10/16 at 10:00 a.m., toured the East Wing nourishment rooms with the Director of Dietary Services (DFS) who agreed there is an accumulation of calcium on the ice machines. DFS said the filters on the machine are changed at least yearly, or more often if needed. DFS said the calcium does build up on the machines all the time, and the machines are usually cleaned weekly. The DFS said she would be addressing the issue of the calcium buildup with the Director of Plans and Operation (DPO).
On 6/10/16 at 11:00 a.m., the DPO said the filters of the ice machine are usually changed more often than yearly, due to the high concentration of calcium in the city water. The DPO said the facility does not have a water softener system in place for the cold water in the facility because it would be too costly. The DPO said some of the parts on the ice machine are plastic and very porous, and need to be replaced. The replacement parts are expensive, and are only changed when they are really bad. He agreed the ice machines should be part of a preventitve maintance program.
On 6/11/16 at 11:20 a.m., a phone conversation was conducted with the DPO about water quality testing. The DPO said the facility does not test the quality of the water.
A review of the facility's approved policy titled "Preventive Work Order" states: "Check water filter and change if need or annually. Check date on filter for verification of date of last change out." The policy does not address the prevention of large calcium deposits in and on the ice machines.
Refer to manufacturer's service manual for specific tasks not included in the procedures provided in this work order.
"1. Clean water side of systems.
2. Clean compressor compartment of machine.
3. Check safety's.
4. Check for refrigerant leaks and proper frost line, which should frost out of the accumulator no closer than 8-12 inches from compressor."