HospitalInspections.org

Based on staff interview, review of complaint and grievance reports, and review of facility policy and procedure, it was determined the facility failed to ensure that a resolution of a grievance includes a written letter sent to the grievant within seven (7) days, in accordance with facility policy and procedure.

Findings include:

Reference: Facility policy, "Reporting & Resolution of Patient Complaints and Grievances" last reviewed February 2022, states, " ... 2. Grievance - A formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the following... a. Patient care complaint that is not resolved at the time of the complaint by the staff or leader present including the following... Complaint that requires investigation... b. Complaint involving/alleging a violation of the patient's right including abuse, neglect, or [initials of facility] failure to comply with a CMS requirement. ... Procedure... 2. If a complaint is unable to be resolved at the point of service, the staff will immediately notify the departmental manager/director. He or she will initiate the grievance process. ... 6. The Vice President of Operations... in collaboration with the investigating departmental manager/director, will provide the grievant a written letter based upon one of the following criteria being met within seven (7) days from the date the grievance was identified: a. The grievance investigation is completed and resolution has been obtain [sic]; b. The grievance is not resolved and additional days are needed... ."

A request was made to Staff #1 for any complaints or grievances reported to the facility on behalf of Patient #1. Staff #1 provided a complaint report entered on 3/24/21 by patient #1's next of kin. The complaint report identified three (3) issues lodged by the grievant, with each issue item stating, "Issue Resolution Date 4/30/21." There was no evidence that a written letter was sent to the grievant within seven (7) days of the grievance being identified.

Upon interview on 4/18/22, Staff #1 confirmed that the issues presented by the grievant required further investigation, escalating the issues from complaints to grievances. Staff #1 confirmed that there was no written letter sent to the grievant within seven (7) days of the grievance being identified.

Based on medical record review, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure that patient representatives of incapacitated patients are kept informed about the patient's health status.

Findings include:

Reference: Facility policy titled, "Patient Rights" last reviewed June 2021, states, "... As a patient at [name of facility], you have the following rights... The right to receive an understandable explanation from your physician of your complete medical condition, recommended treatment, expected results, risks involved, and reasonable medical alternatives. If your physician believes that some of this information would be detrimental to your health or beyond your ability to understand, the explanation must be given to your next of kin or guardian, unless prohibited in accordance with federal law. ... ."

Review of medical record #1 on 4/18/22 revealed the patient arrived to the ED (Emergency Department) on 3/18/21 at 3:20 PM with a chief complaint of altered mental status. Hospital Medicine Progress Notes dated 3/19/21 at 11:04 AM state, "... Review of Systems... Psych: Positive for confusion... Neurological... Comments: Patient delirious, waxing and waning; At times AAOx3 (awake, alert, and oriented to person, place, and time) at times unable to respond; Speech garbled. ... Assessment and Plan... Patient presented to the ED with chief complaint of altered mental status. Upon arrival patient was AOx3 and was deemed to be stable at his baseline. However he has had waxing and waning mental status since that point."

ED provider notes dated 3/18/21 at 3:50 PM state, "Discussed with patient's daughter..." and lists the name and phone number of the patient's daughter. Case Management progress notes dated 3/19/21 at 11:00 AM indicate that the source of information for the patient's discharge evaluation was the patient's daughter.

An APN (advanced practice nurse) progress note dated 3/20/21 at 1:51 PM states, "... Patient refusing telemetry per nursing." Due to the decline in the patient's mental status, he/she would lack the capacity to understand the risks involved with refusing treatment. There was no evidence in the medical record that the patient's daughter, or any other family member, was notified that the patient was refusing telemetry and was not receiving cardiac monitoring services.

Results from a swallowing evaluation performed on 3/22/21 at 11:07 AM states, "Impressions: swallow not functional, pt (patient) drowsy, wet respiration prior PO (by mouth), pt triggered a single swallow despite delayed oral transfer of 1/4 tsp. Swallow absent to delayed, reduced minimal laryngeal elevation palpated and increased respiratory congestion= suspected high aspiration risk... Diet Recommendations: Strict NPO (nothing by mouth)... Education: Results and recommendations discussed w/pt (with patient), safety sitter, Dr. and RN." There was no evidence in the medical record that the patient's daughter, or any other family member, was notified about the patient's results from his/her swallowing evaluation or his/her subsequent change in diet. At 1:50 PM, Staff #8 confirmed that there was no evidence in the medical record that the patient's next of kin was notified regarding the results from the patient's swallowing evaluation and subsequent diet change.

A physician's progress note dated 3/23/21 at 1:39 AM states, "Called by nursing for restraint order. Pt being combative/agitated. Pt unable to be verbally redirected. Placed in bilateral soft wrist restraints for protection of lines/tubes and self harm. ... ." There was no evidence in the medical record that the patient's daughter, or any other family member, was notified that the patient was placed in restraints. At 1:50 PM, Staff #8 confirmed that there was no evidence in the medical record that the patient's next of kin was notified that the patient was placed in restraints.

Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) vital signs are taken every four (4) hours for patients who are on telemetry monitoring; 2) a physician's order to discontinue telemetry monitoring is obtained for patients refusing telemetry monitoring, in accordance with facility policy.

Findings include:

1) Reference: Facility policy, "Vital Signs/Weights" last reviewed August 2021, states, "... It is the policy of [name of facility] that routine vital signs shall be taken and recorded a minimum of every eight hours unless otherwise specified by physician/unit protocol. ...Vital signs may be obtained and recorded more frequently than every four to eight hours as clinically indicated."

Upon interview on 4/18/22, Staff #8 and Staff #25 stated that vital signs are taken a minimum of every four (4) hours for patients on telemetry monitoring. Staff #8 stated, "I don't know if it's in the policy, but patients that are monitored are supposed to have vital signs taken every four (4) hours." Upon interview, Staff #8 stated that a full set of vital signs includes a check for blood pressure, temperature, pulse, and respirations.

Review of medical record #1 on 4/18/22 revealed the following:

The patient arrived to the ED on 3/18/21 at 3:20 PM and was admitted to the facility. The patient was transferred to 3 West on 3/18/21 at 8:21 PM with an order for telemetry monitoring. Review of the nursing flowsheets revealed that vital signs were not taken every four (4) hours on the following dates and times:

a. Vital signs were documented on 3/19/21 at 12:13 AM. The next set of vital signs were documented on 3/19/21 at 6:53 AM, six (6) hours and forty (40) minutes after the previous set of vital signs were taken.

b. Vital signs were documented on 3/19/21 at 2:35 PM. The next set of vital signs were documented on 3/19/21 at 8:10 PM, five (5) hours and thirty-five (35) minutes after the previous set of vital signs were taken.

c. Vital signs were documented on 3/20/21 at 11:12 AM. The next set of vital signs were documented on 3/20/21 at 6:49 PM, seven (7) hours and thirty-seven (37) minutes after the previous set of vital signs were taken.

d. Vital signs were documented on 3/20/21 at 11:31 PM. The next set of vital signs were documented on 3/21/21 at 5:04 AM, five (5) hours and thirty-three (33) minutes after the previous set of vital signs were taken.

e. Vital signs were documented on 3/22/21 at 6:54 AM. The next set of vital signs were documented on 3/22/21 at 3:50 PM, eight (8) hours and fifty-six (56) minutes after the previous set of vital signs were taken.

f. Vital signs were documented on 3/22/21 at 3:50 PM. The next set of vital signs were documented on 3/23/21 at 2:38 AM, ten (10) hours and forty-eight (48) minutes after the previous set of vital signs were taken.

At 3:10 PM, Staff #1 and Staff #8 confirmed that vital signs were not taken every four (4) hours for patients being monitored on telemetry.

2) Reference: Facility policy titled, "Admission/Discharge Telemetry Criteria" last reviewed May 2021 states, "... Telemetry ECG (electrocardiogram) monitoring is ordered by the LIP (licensed independent practitioner). The medical necessity is reassessed every 48 hours. ... Procedure... Steps... 1. An order will be placed by the LIP for Cardiac Monitoring by Protocol with the required indication and transportation status... 2. The RN will measure and interpret rhythm strips on admission or transfer to a monitored unit, shift change, with any rhythm change from the patients' baseline, and for arrhythmias listed on the indications for continuation of telemetry... Key Points... Strips will be six seconds in length. Strips will be identified with patient's name, room number, date and time. ... 5. Notify LIP for patients refusing continuous cardiac monitoring. Key Points... An order must be obtained to discontinue telemetry. ... ."

Review of medical record #1 on 4/18/22 revealed the patient arrived to the ED on 3/18/21 at 3:20 PM with a chief complaint of altered mental status. A 12-lead EKG was performed at 3:41 PM, with the results indicating the following: "Impression: Sinus rhythm with 1st degree AV block with premature atrial complexes; Right bundle branch block; Possible Inferior infarct, age undetermined; Abnormal ECG when compared with ECG of 28-OCT-2019 08:52... ." The patient was transferred to 3 West on 3/18/21 at 8:21 PM with an order for telemetry monitoring.

An APN (advanced practice nurse) progress note dated 3/20/21 at 1:51 PM states, "... Patient refusing telemetry per nursing." There was no evidence in the medical record that the APN, or the physician, wrote an order to discontinue the patient's telemetry monitoring.

From 3/18/21 to 3/23/21, while the patient was admitted to 3 West, three (3) telemetry rhythm strips were documented for patient #1 on the following dates and times: 3/20/21 at 11:21 PM, 3/22/21 at 1:51 AM, and 3/22/21 at 6:51 AM. There was no cardiac rhythm indicated on the rhythm strips and each rhythm strip had the word "refused" written on the strip.

Documentation in the medical record revealed the patient experienced a "code blue" on 3/23/21 at 7:00 AM and was transferred to the Intensive Care Unit (ICU). Intensive Care Consult notes dated 3/23/21 at 1:48 PM state, "... Was not on telemetry prior to the arrest because he was agitated and pulling his leads off. ... ."

During a tour of the telemetry monitoring room on 4/18/22 at 12:40 PM, patient #5 and patient #6 had notes on the cardiac monitor that state, "Refuse." Upon interview, Staff #18 stated, "We cannot make patients wear a monitor if they are refusing. The physician won't d/c (discontinue) it because it's needed. If they refuse, the doctor is notified and it is up to the physician if the patient needs to be monitored." At 1:15 PM, Staff #18 stated, "I print a strip (telemetry rhythm strip) every shift. Nurses on 3 West, 4 East, and 4 West can print their own."

During an interview on 4/18/22 at 3:25 PM, Staff #24 stated, "I was not aware the patient (patient #1) was refusing telemetry. The next course of action would be non-violent restraints if the telemetry is needed. Otherwise, if telemetry is not necessary, then the tele (telemetry) should be d/c to free up the tele monitor."

On 4/18/22, Staff #1 and Staff #4 confirmed that there was no evidence of a physician order to discontinue telemetry in patient #1's medical record.