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Based on record review and interview, the facility failed to review, investigate, and attempt to resolve patients grievances within a reasonable time frame in 4 (P4, P5, P7, P8) of 5 cases reviewed. This deficient practice has the likelihood to result in dissatisfied patients with outstanding grievances for extended periods of time, and may impair the facility's ability to identify and improve on issues that are of concern to their patients.



Findings:

A. Record review of facility policy "Patient/Family Complaints/Grievance" (updated 03/2020) states, "A written notice will be provided to the complainant within 10 working days and will include: i. Name of facility person responding. ii. Steps taken on behalf of the complainant. iii. Results of the grievance, with completion date..."


B. On 06/17/20 at 8:45 am, during interview, S2 (COO - Chief Operating Officer) displayed on computer screen and explained that the facility's grievance process system (GPS) uses electronic format and includes data entry, communication, and response from multiple different involved staff members. This GPS is generated in response to a grievance from a patient (or patient's family member or representative) of the facility. Tab 1 (T1, step 1) is labeled "Event", what is the grievance. Tab 2 (T2, step 2) is labeled "Facts", what is determined to have happened regarding this grievance. Tab 3 (T3, step 3) is labeled "Notification", what staff member was notified of the grievance and what corrective action was taken. Tab 4 (T4, step 4) is labeled "Review", an appropriate director/supervisor for that area of grievance approves the "Notification" action, or recommends further corrective actions. Tab 5 (T5, step5) is labeled "Finalization", the grievance is reviewed by S2 (COO- Chief Operating Officer) or S6 (SO- Safety Officer/Risk Manager Services Director) and they recommend further corrective actions, or "finalize" and close/resolve the grievance.


C. Record review of facility grievance involving P4 (Patient #4) revealed that on 06/01/20 at 8:30 am, in room (#305-A) of the Medical Surgical Pediatric (MSP) unit, P4 stated that a Respiratory Therapist (RT) was rude to her regarding P4's use of her respiratory inhaler medication. On 06/01/20, S17 (MSP Manager) spoke with the P4, apologized for RT's comments and spoke with S15 (RT supervisor) about the grievance. The RT apologized to P4 the next day. S15 (COO) did not enter this information into the grievance process system (GPS) until 06/14/20. On 06/17/20, S8 (DOS - Director of outpatient services) "concurred" with the action taken. During review on 6/18/20, this grievance was still awaiting "Finalization" by S2 (COO) or S6 (Safety Officer), i.e. it was not yet resolved (closed or completed).


D. Record review of facility grievance involving P5 (Patient #5) revealed that on 05/18/20 at 4:44 PM, P5 was upset about her bill from the facility and threatened to sue the facility. This grievance was forwarded to S26 (Senior Director of Revenue) on 05/27/20. There is no documentation in the GPS from S26 regarding this grievance or any action taken regarding it. During review on 06/18/20 this grievance was not yet resolved.


E. Record review of facility grievance involving P6 (Patient #6) revealed that P6 had been an inpatient on the Medical Surgical Pediatric (MSP) unit and was discharged (d/c'd) on 06/02/20 to a Long-Term Care facility (LTC). On 06/03/20 at 12:02 PM, S17 (MSP Manager) received an email from P6's daughter who was upset that he was d/c'd to the LTC. She had wanted P6 to be d/c'd to their home. Documentation showed that the facility's plan was to d/c P6 to LTC, and that this daughter was informed of this plan. On 06/04/20 at 11:10 am, S39's (Case management director) GPS entry was "No actions taken at this time." On 06/15/20 at 6:13 PM this grievance was listed as "Finalized" by S6.


F. Record review of facility grievance involving P7 (Patient #7) revealed that in room (#310) on the MSP unit on 05/08/20 at 1:00 am, P7 was unhappy with her care received from a Patient Care Technician (PCT) and P7's increased length of time waiting for the PCT to attend to her. On 05/08/20 at 2:35 PM, S17's (MSP Manager) GPS (Grievance Process System) entry stated that S17 spoke with P7's nurse and instructed the nurse to "make the patient happy and comfortable". On 5/22/20 at 10:22 am, S17's GPS entry noted that she had spoken with the patient and the PCT involved and that "appropriate actions were taken". On 06/01/20, S17's GPS entry stated a "Corrective Action" taken: S17 talked with the Charge nurses and told them to check patient acuity levels (how much staff care and time a patient (pt.) requires) before doing pt. assignments for the PCT's. On 06/17/20 S6 (Safety Officer) entered a "De-Finalized" note in the GPS, stating "Additional follow up with S17 needed." During review on 06/18/20 this grievance was still not resolved.


G. Record review of facility grievance involving P8 (Patient #8) revealed that on 03/28/20 at 1:00 PM, a grievance was received via phone call regarding the MSP unit. It was entered into GPS on 03/28/20 at 2:34 PM, by S2 (COO). P8's significant other (S/O) called and complained about a nurse that was rude to her on the phone. S2 told S/O that he would notify the Director (of MSP unit) and the CEO. S2 called S17 (MSP Manager) that same day and informed her of grievance. On 06/01/20, S17 made a GPS entry stating that she had talked to the nurse (RN) identified in the grievance and that "this RN is PRN (on call, part time employee)". During review it was revealed that "the Review tab is pending" (in the GPS), meaning that S17 had not completed her part of this grievance yet. During review on 06/18/20, this grievance was still not resolved (closed or completed).

Based on record review and interview, the facility failed to review, investigate, and inform patients (pts.) who had filed a grievance, with a written response to the patient's grievance in 5 (P4, P5, P6, P7, P8) of 5 cases reviewed. This deficient practice has the likelihood to result in dissatisfied patients who have not received a written response clarifying or correcting their grievance, and may impair the facility's ability to identify and improve on issues that are of concern to their patients.


Findings:

A. Record review of facility policy "Patient/Family Complaints/Grievance" policy (updated 03/2020) states that, "A written notice will be provided to the complainant within 10 working days and will include: i. Name of facility person responding. ii. Steps taken on behalf of the complainant. iii. Results of the grievance, with completion date..."


B. On 06/17/20 at 8:45 am, during interview, S2 (COO - Chief Operating Officer) displayed on computer screen and explained that the facility's grievance process system (GPS) uses electronic format and includes data entry, communication, and response from multiple staff members. This GPS is generated in response to a grievance from a patient (or patient's family member or representative) of the facility. Tab 1 (T1, step 1) is labeled "Event", what is the grievance. Tab 2 (T2, step 2) is labeled "Facts", what is determined to have happened regarding this grievance. Tab 3 (T3, step 3) is labeled "Notification", who was notified of the grievance and what corrective action was taken. Tab 4 (T4, step 4) is labeled "Review", an appropriate director/supervisor for that area of grievance approves the "Notification" action, or recommends further corrective actions. Tab 5 (T5, step 5) is labeled "Finalization", the grievance is reviewed by S2 (COO- Chief Operating Officer) or S 6 (SO- Safety Officer/Risk Manager Services Director) and they recommend further corrective actions, or "finalize" and close/resolve the grievance.


C. Record review of facility grievance involving P4 (Patient #4) revealed that on 06/01/20 at 8:30 am, in room (#305-A) of the Medical Surgical Pediatric (MSP) unit, P4 stated that a Respiratory Therapist (RT) was rude to her regarding P4's use of her respiratory inhaler medication. On 06/01/20, S17 (MSP Manager) spoke with the P4, apologized for RT's comments and spoke with S15 (RT supervisor) about the grievance. The RT apologized to P4 the next day. S15 (RT supervisor) did not enter this information into the grievance process system (GPS) until 06/14/20. On 06/17/20, S8 (Director of outpatient services) "concurred" with the action taken. During review on 6/18/20, this grievance was still awaiting "Finalization" by S2 (COO) or S6 (Safety Officer), i.e. it was not yet resolved (closed or completed).


D. Record review of facility grievance involving P5 (Patient #5) revealed that on 05/18/20 at 4:44 PM, P5 was upset about her bill from the facility and threatened to sue the facility. This grievance was forwarded to S26 (Senior Director of Revenue) on 05/27/20. There is no documentation in the GPS from S26 regarding this grievance or any action taken regarding it. During review on 06/18/20 this grievance was not yet resolved.


E. Record review of facility grievance involving P6 (Patient #6) revealed that P6 had been an inpatient on the Medical Surgical Pediatric (MSP) unit and was discharged (d/c'd) on 06/02/20 to a Long-Term Care facility (LTC). On 06/03/20 at 12:02 PM, S17 (MSP Manager) received an email from P6's daughter who was upset that he was d/c'd to the LTC. She had wanted P6 to be d/c'd to their home. Documentation showed that the facility's plan was to d/c P6 to LTC, and that this daughter was informed of this plan. On 06/04/20 at 11:10 am S39's (Case management director) GPS entry was "No actions taken at this time." On 06/15/20 at 6:13 PM this grievance was listed as "Finalized" by S6.


F. Record review of facility grievance involving P7 (Patient #7) revealed that in room #310 on the MSP unit on 05/08/20 at 1:00 am, P7 was unhappy with her care received from a Patient Care Technician (PCT) and P7's increased length of time waiting for the PCT to attend to her. On 05/08/20 at 2:35 PM, S17's (MSP Manager) GPS (Grievance Process System) entry stated that S17 spoke with P7's nurse and instructed the nurse to "make the patient happy and comfortable". On 5/22/20 at 10:22 am, S17's GPS entry noted that she had spoken with the patient and the PCT involved and that "appropriate actions were taken". On 06/01/20, S17's GPS entry stated a "Corrective Action" taken: S17 talked with the Charge nurses and told them to check patient acuity levels (how much staff care and time a patient (pt.) requires) before doing pt. assignments for the PCT's. On 06/17/20, S6 (Safety Officer) entered a "De-Finalized" note in the GPS, stating "Additional follow up with S17 needed." During review on 06/18/20, this grievance was still not resolved.


G. Record review of facility grievance involving P8 (Patient #8) revealed that on 03/28/20 at 1:00 PM, a grievance was received via phone call regarding the MSP unit. It was entered into GPS on 03/28/20 at 2:34 PM, by S2 (COO). P8's significant other (S/O) called and complained about a nurse that was rude to her on the phone. S2 told S/O that he would notify the Director (of MSP unit) and the CEO. S2 called S17 (MSP Manager) that same day and informed her of grievance. On 06/01/20, S17 made a GPS entry stating that she had talked to the nurse (RN) identified in the grievance and that "this RN is PRN (on call, part time employee)". During review it was revealed that "the Review tab is pending" (in the GPS), meaning that S17 had not completed her part of this grievance yet. During review on 06/18/20 this grievance was still not resolved (closed or completed).


H. On 06/18/20 at 3:30 PM, during interview, S2 (COO - Chief Operating Officer) confirmed that there was no documentation indicating that any written response was provided by the facility to these patient's (P4, P5, P6, P7, P8) grievances in any of the above referenced grievance events (C.- G.).

Based on record review and interview, nursing care was not provided in a safe setting when accepted standards of practice were not followed to ensure correct endotracheal tube (ET hollow plastic tube placed in the airway) placement for 1 (P#1) of 15 patient records reviewed. This deficient practice may have resulted in patient death due to inadequate mechanical ventilation to a critically ill patient after facility staff made adjustments to the placement of the ET tube.


A. Record review of an article published by "Searchlight New Mexico" dated 05/08/20 revealed, "According to two physicians, a COVID-19 patient spent the night of April 26, 2020, on a maladjusted ventilator. (The equipment, which pushes oxygen to the lungs) had slipped out of the trachea (windpipe) and was resting in the patient's mouth, rendering it useless for hours. The patient died in the following days."


B. Record review of Provider Note dated 04/16/20 revealed, P#1 was admitted to the facility on 04/10/20, and required intubation endotracheally (unable to breath and required a breathing tube be inserted into the trachea) due to worsening respiratory failure on 04/16/20.


C. Record review revealed problems with P#1's ET tube including:

1. Operative Note dated 04/23/20, revealed, P#1 self-extubated (removed the endotracheal tube himself and was reintubated with an 8.0 (unit of measurement for ET tubes) ET tube with gleidoscope assistance.

2. Nursing Note dated 04/23/20 at 0545 (5:45 am), revealed, "RT (Respiratory Therapist) in to assess pt (patient); RT stated that the cuff balloon surrounding ET tube inflated to keep ET tube in place in the windpipe (trachea) may be busted and extubated himself from moving his head side to side when awake. ET tube 8.5 (increased tube size)."


D. Record review of Chest X-rays reviewed by radiologist:

1. 04/26/20 4:27 am, revealed, "ET tube is in place, tip is at the clavicle."

2. 04/26/20 at 11:20 PM, revealed, "Endotracheal tube is 9 cm (unit of measure) above the carina. Advance the tube approximately 3 cm for better positioning."

3. 04/27/20 at 7:42 am revealed, "ET terminating adjacent to the left lung apex (rounded upper extremity of either lung). It is not clear that this is within the trachea and could be within the hypopharynx (back of the throat). If within the trachea (windpipe) this would need to be advanced about 6 cm (unit of measurement) and reimaged (repeat X-ray) for confirmation."


E. Record review of Nurse Notes:

1. 04/26/20 at 11:45 PM, revealed, "Radiologist from radiology service called and informed me that the tube needed to be advanced 3 cm. Told her I appreciated call and would do so immediately which had been done earlier when pt (patient) was in distress."

2. 04/27/20 at 5:03 am, by RN "AM ABGs done. PCO2 122 DR [name of doctor] CALLED."


F. Interviews:

1. On 06/17/20 at 3:45 PM, during interview, S#15 (Lead RT Respiratory Therapist) confirmed multiple problems with P#1's ET tube from the initial intubation on 04/16/20 including, that "it just popped out" once when the staff was preparing to reintubate. S#15 also confirmed that the machine alarms were not turned off on 04/26/20 or 04/27/20 and confirmed the ventilator was not maladjusted because alarms would have sounded.

2. On 06/17/20 at 4:15 PM, during interview, S#16 RN (Registered Nurse) confirmed there were multiple problems with P#1's ET tube in the period from initial intubation on 04/16 thru 04/27/20 including the balloon (cuff) was hyperinflated (more than the usual amount of air inserted into the balloon to ensure the ET tube does not become dislodged or is accidentally inserted too far into the trachea) and on another occasion, the ET tube became dislodged as MD (Medical Doctor) was in the room setting up for reintubation. RN confirmed the ventilator may not have alarmed after the ET was being advanced (on 04/26/20) because the balloon was hyperinflated and sitting in the back of P#1's throat.

3. On 06/18/20 at 10:05 am, during interview, S#14 RN confirmed adequate orientation to facility was provided, RN had greater than 10 years of ICU (intensive care unit) experience, and that the ET tube advancement was performed by the interviewee, but the procedure is usually performed by a Respiratory Therapist. RN confirmed the Hospitalist was not reached for an X-ray order to confirm ET tube placement after advancement and multiple problems had been identified with the ET tube during the period after P#1 was initially intubated on 04/16/20. RN also confirmed, "removing an excessive amount of air" when deflating the balloon to advance the ET tube, and no nursing supervisory staff was involved to assist with obtaining an order to verify placement after advancing the ET tube.

4. On 06/18/20 at 2:30 PM, during interview CNO (Chief Nursing Officer) and Manager of Intensive Care confirmed:

a. Advancement of the ET tube by the Registered Nurse on 04/26/20 should have been verified by X-ray to confirm proper placement.

b. If RN was unable to reach physician for an order for X-ray after advancing the ET tube, the chain of command should have been followed including contacting the CMO (Chief Medical Officer) and/or the ED (Emergency Department) physician.

c. The facility does not have a policy currently in place to determine who should adjust the tube placement and the verification process required to determine that the adjustment carried out resulted in proper ET tube placement. The MD (medical doctor) usually writes the orders for X-rays.


G. Record review of "Pulmonary Management" included in ICU nurse orientation revealed, normal PCO2 range is 35-45. P#1's PCO2 was 77 points higher than accepted normal range.


H. Record review of facility policy "Chain of Command for Providers (Non-Responding and Disagreements)" dated 04/2018 revealed, "If a nurse or other staff questions or disagrees with a provider's order or management of a case, and believes the patient's safety of well-being may be at risk, this individual has the responsibility of communicating this concern using the procedures herein to resolve the issue. If the provider and nurse or other staff disagrees about the appropriateness of an order or management of a case and if the safety or well-being of the patient continues to be a question, it is the responsibility of the nurse or other staff to communicate this concern to the Director or House Supervisor who will then contact Medical Staff leadership (department chair, Chief of Staff - past, present, or elect."


I. Record review of "Do Current Methods for Endotracheal Tube Cuff Inflation Create Pressures Above the Recommended Range? A Review of Evidence" Journal Perioperative Practice dated 2013 revealed, "The morbidity associated by an overinflated (hyperinflated) cuff has been regularly highlighted in literature, for example mucosal ulceration (ulcer development) and vocal cord paralysis (vocal cords unable to open and close properly, important for breathing speaking and swallowing)."


J. Record review of "Repositioning Endotracheal Tubes in the Intensive Care Unit: Depth Changes Poorly Correlate With Postrepositioning Radiographic Location" Journal Trauma Acute Care Surgery 2013 Jul:75(1) revealed, "ET repositioning based on measurement at the incisors (advancement or withdrawal) is inaccurate and the magnitude of the intervention does not correlate with the degree of error. Repositioning of ETs based on measurements at the incisors should be abandoned, or follow-up CXR (chest X-ray) images be obtained."


K. Record review of Pulmonologist Note dated 04/29/20 at 1700 (5:00 PM), revealed, "Called to bedside for suspicion of death. Patient terminally extubated (endotracheal tube removed) under comfort measures only. Patient unresponsive to verbal or painful stimuli (confirmation of death)."