HospitalInspections.org

Based on interview and record review, the hospital's GB failed to ensure the effective operation of the grievance process for one of two grievances reviewed (for Patient 47). Patient 47's grievances were not thoroughly investigated and there was no documented evidence a written communication was provided to the patient reflecting the results of the investigation and actions taken as per the hospital's P&P. These created the risk of not addressing the grievances for this patient.

Findings:

The hospital's P&P titled Complaints and Grievances, Patient dated 12/15/14, showed a letter or electronic email is considered a grievance. This includes written complaints from an inpatient, an outpatient, a released discharged patient, or a patient's representative regarding patient's care. A patient grievance is a written letter or email made during an admission or a verbal complaint made to the hospital by the patient or the patient's representative regarding the patient's care.

All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported.

Once a concern or complaint has been identified as a grievance, every attempt will be made to resolve the grievance within seven calendar days or as soon as possible. The patient and/or patient's representative will receive written communication from the organization within seven calendar days of the receipt of the grievance (seven calendar days is timed from the initiation of the grievance). The communication shall outline the results of the investigation and actions taken.

On 1/13/15, review of the hospital's event log showed the sections to document the patient/person affected, event type, narrative description, and management review.

The hospital's event log showed an entry for "Grievance" type event for Patient 47. The document showed Patient 47 had notified the hospital on 1/2/15, of concerns regarding care received on 12/31/14. The concerns included the nurse had ignored the patient, was argumentative, and did not manage the patient's pain effectively. The sections for the dates of sending out the 7-day and final letters to the person who filed grievances were left blank. There was no documentation of any medical record review or staff interviews in response to the patient's allegations.

The Management Review section of the event log for Patient 47's grievances indicated the Department Manager spoke with the patient briefly prior to discharge. The patient had recommended to list the nurse as a DNR staff. The file status indicated the file was signed off by the primary Manager.

Further review of the document showed no documented evidence of the investigation and written notification provided to the patient regarding the results of the investigation and actions taken to resolve the patient's grievances as per the hospital's P&P.

During an interview with the Director of QA on 1/14/15 at 1345 hours, she stated there was no documentation in the incident database regarding review of the medical record or staff interviews conducted related to Patient 47's concerns. She stated she thought Patient 47's allegations were a complaint, not a grievance because they were written on a comment card. She stated if the patient had emailed the concerns, they would be considered as a grievance. The Director of QA further stated the Department Manager had spoken to the patient and told her the patient was satisfied. She stated the grievances were to have an investigation and the 7-days and final letters were to be sent to the patient/patient's representative.

During an interview with the Department Manager on 1/15/15 at 1300 hours, she stated she did speak with the patient about the concerns. She stated she did not review the patient's medical record regarding pain medication administration because she thought Patient 47's concerns were more about the nurse's attitude issues.

Based on interview and record review, the hospital failed to ensure a safe environment for one patient of 29 sampled patients (Patient 49). Used patient care items such as IV tubings of the IV fluid and antibiotic bags were not properly removed from the room prior to Patient 49 moving into that room. As a result, Patient 49 was attached to the IV tubings of the IV fluid and antibiotic bags that belonged to another patient who had previously occupied the room. There was no documented evidence the disclosure of the event including unanticipated outcomes was provided to Patient 49. This created the risk of violating the patient's right to be in a safe environment and not fully informing the patient regarding unanticipated outcomes from the incident.

Findings:

The hospital's P&P titled Guidelines for Open Communication of Unanticipated Outcomes effective 5/1/09, read in part, "Patients, and where appropriate, their families are informed about the outcomes of care, including unanticipated outcomes. The practitioner and/or representative of hospital administration will disclose what is to be communicated. Disclosure of the event will take place as close as possible to the awareness of the event."

Review of the hospital's incident log on 1/13/15 at 1035 hours, an incident report involving Patient 49 dated 1/4/15, was reviewed with RN 14. During a concurrent interview, RN 14 stated the IV fluid and Vancomycin (antibiotic) medication bags with the IV tubings of the patient who previously occupied the room were left in the room after the patient had been transferred to another hospital. Patient 49 was moved into that room and was attached to the IV tubings of the IV fluid and Vancomycin medication bags that belonged to the transferred patient.

During an interview with MD 1 on 1/13/15 at 1150 hours, he stated he was not sure if Patient 49 was told of a possible exposure to disease from the incident.

During an interview with the Interim Director of IP and IP Consultants 1 and 2 on 1/13/15 at 1420 hours, they reviewed the event details for the re-use of the IV tubings, and stated the use of the IV tubings by the two patients should be treated as potential blood exposure for the second patient (Patient 49).

The documentation of incident disclosure to Patient 49 was requested on 1/13/15, but was not provided as of the exit date on 1/15/15. The hospital failed to provide a disclosure of the event including unanticipated outcomes as per the hospital's P&P.

During an interview with the Interim Director of IP on 1/15/15 at 0845 hours, she stated she did not believe there had been a disclosure to Patient 49 regarding a potential blood exposure.

Based on interview and medical record review, the hospital failed to ensure the physician had completed the discharge summary as per the hospital's Medical Staff Bylaw for one of 29 sampled patients (Patient 37), creating the risk of a substandard healthcare outcome to this patient.

Findings:

The Medical Staff Bylaws approved 11/17/14, read on pages 12-13, "Each member of the medical staff shall: ...Prepare and complete in timely fashion the medical and other required records for all patients he admits or in any way provides care to in the hospital including compliance with such electronic health record policies and protocols as have been implemented". The Medical Staff Policies and Procedures regarding Medical Record Documentation revised 2/12, read, "A record is considered delinquent if not completed within fourteen (14) days of discharge."

Review of the medical record for Patient 37 was conducted on 1/12/15. The medical record showed the patient came to the ED on 12/23/14, and was discharged at 1050 hours. There was a discharge summary dictated by the physician, but the document was not signed by the physician.

During a concurrent interview with RN 19, he stated the physician did not sign the discharge summary in a timely fashion. The blank signature line showed "This is not considered FINAL until Signed by a Physician."

Based on observation, interview, and medical record review, the hospital failed to ensure nursing staff developed a specific care plan to address the care needs for positive influenza and/or droplet precautions for one of 29 sampled patients (Patient 42). This created the risk of not providing appropriate, consistent, and quality care to this patient.

Findings:

During an observation on 1/12/15 at 1530 hours, Patient 42 was observed staying in a room with droplet precautions.

Review of Patient 42's medical record was initiated on 1/12/15. The patient was readmitted to the hospital on 1/9/15.

The History & Physical Report dictated on 1/10/15 at 0932 hours, showed Patient 42 was readmitted one day after discharge from the hospital. The patient's influenza screen showed a positive result for influenza virus type A.

However, review of the Patient's Plan of Care-General Medical failed to show a care plan was developed to address the patient's care needs related to influenza and droplet precautions.

An interview and concurrent medical record review was conducted with RN 11 and the Nurse Manager Med/Surg on 1/12/15 at 1530 hours. RN 11 stated Patient 42 was placed on droplet precautions for a positive influenza. When asked, RN 11 was unable to find documented evidence to show a care plan was developed to address the patient's care needs related to influenza and droplet precautions.

Based on interview and record review, the hospital failed to ensure the H&P examinations were complete within 30 days of the admission for two of 29 sampled patients (Patients 34 and 35), creating the risk of substandard health outcomes to these patients.

Findings:

1. The Medical Staff Bylaws dated 11/17/14, read on page 14, "Assure prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies, a medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration."

The Medical Staff Policies and Procedures, Medical Record Documentation dated 10/9/13, showed the H&P is to include a chief complaint, relevant past, family and social history, all pertinent findings resulting from an assessment of all the systems of the body, a thorough physical examination, an admitting diagnosis, and a statement for the course of action planned for the patient while in the hospital.

The medical record of Patient 35 was reviewed on 1/12/15, and showed the patient came to the GI center on 1/7/15, for a colonoscopy with multiple biopsies. The record contained a 2 ½ page typed comprehensive H&P examination dated 11/19/14, 54 days prior to the procedure date. The record also contained a Short Form History and Physical Examination dated 1/7/15, but that document omitted most the of patient's medical history, review of systems, surgical history, family and social history, and medications.

In an interview with the CMO on 1/13/15 at 1030, she concurred the 1/7/15 H&P examination was incomplete and the 11/19/14 H&P examination was completed more than 30 days prior to the date of the procedure.


22553


2. The hospital P&P titled Moderate/Deep/Dissociative Sedation/Analgesia Administration for Non Anesthesia Providers reviewed 3/12, showed all patients receiving conscious (moderate) sedation will receive a comparable standard of care and be monitored by appropriately qualified personnel throughout the medical center. The equipment in the procedure room include a CO2 monitoring equipment. The requirements for the number of qualified individuals for moderate sedation include the physician to complete the Pre-Moderate/Deep/Dissociative Sedation Patient Evaluation. The Physician should complete a H&P assessment to include heart, lung, and airway assessment with ASA scores relevant to the patient's diagnosis, condition, and proposed procedure prior to the procedure. An interval note within 24 hours prior to the procedure identifying any changes is to be completed by the physician performing the procedure.

On 1/12/15 at 1057 hours, during an interview with Patient 34, the patient stated he was deaf to the right ear and asked the surveyor spoke to his left ear. In addition, the patient stated he had two times of the colonoscopy examinations and polyps were removed in the past, and this was his third time follow-up colonoscopy examination. The patient also stated he had asthma and used inhaler daily.

During the time out observation of the procedure on 1/12/15 at 1140 hours, the patient was confirmed to be allergic to sulfa drugs and levaquin (antibiotic medication). The patient stated Levaquin could make his throat close up.

Patient 34's medical record review was initiated on 1/12/15 at 1204 hours. The H&P signed by MD 6 on 9/2/14, showed the patient was screened for colonoscopy. The past surgical procedure was not included. The examination for ears showed no change of hearing. The patient's allergies were not documented in the H&P. MD 6 updated and signed this H&P at 1/12/15 at 1020 hours, to indicate "I have reviewed the H&P and examinated the patient. There are no changes from the H&P (9/2/14)."

Review of the Pre-sedation Physician Assessment dated 1/12/15, showed the patient was evaluated utilizing ASA scores and it was appropriate to administer planned moderate sedation. The assessment for ASA classification boxes for both classes I and II was checked (ASA class I: no organic, physiologic, biochemical, or psychiatric disturbance, normal healthy patient and class II: mid-moderate systemic disturbance, may or may not be related to reason for surgery). The assessment for Mallampati classification (used to predict the ease of intubation, it assesses the height of the mouth, the distance from the tongue base to the roof of the mouth to determine the space to work on), showed the box for both classes I and II were checked. The assessment for skin color, oxygen, bowel sounds, and difficulty swallowing were left blank.

On 1/12/15 at 1210 hours, MD 6 was interviewed. MD 6 crossed out the ASA class I and stated the patient should be ASA class II. The above findings were confirmed with QA Analyst at 1210 hours.