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Based on record review and staff interview, the hospital failed to be in compliance with State of Vermont Statute Title 18, Chapter 42: Bill of Rights for Hospital Patients for 1 applicable patient. (Patient # 4). Findings include:

1. Per State Statute 1852. Patients' Bill of Rights for Hospital Patients: "(1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity."

Per record review, Patient #4, age 81 was admitted to the CAH on 3/8/14 with Pneumonia and Congestive Heart Failure. The patient required close monitoring due to his/her fragile respiratory status requiring breathing treatments and intravenous antibiotics. During the night shift for 3/11/14, Patient #4 was assigned Nurse #1. However during the course of the night Patient #4 became upset with Nurse #1 and per nursing progress note states to Nurse #1 " I told you that I did not want you as my nurse. " Despite being told by Patient #4 s/he did not want Nurse #1 providing care and without appreciation of Patient #4 ' s right to considerate and respectful care, at 02:06 on 3/11/14 the Nurse #1 returns to Patient #4 ' s room and describes the patient " ...very hostile ...refused care ...demanded I leave after vital signs " . Eventually there is communication with the nurse manager and Nurse #1 and the patient assignment was changed, eliminating Nurse #1 from being responsible for Patient #4 ' s care needs.

Per interview with the Nurse Surveyor on 3/12/14 at 2:00 PM, Patient #4 confirmed s/he refused to have Nurse #1 on 3/11/14 provide nursing care and was refusing to express to CAH staff his/her specific concerns related to the events on the night of 3/11/14.

Per interview on 3/12/14 at 1:00 PM the Medical Surgical Nurse Manager stated s/he had not made an attempt to visit with Patient #4 to gather information from the patient regarding the circumstances during the night of 3/11/14.

Based on staff interviews and record review the CAH failed to assure care and services were consistently provided in accordance with established policies and procedures for 1 applicable patient. (Patients #4). Findings include:


1. Per review the Patient Complaint and Grievance policy (last revised 02/2014) states the CAH will " .....respond to all patient complaints related to care, treatment, or services ..... " The following procedure states: " A. Upon receipt of a patient complaint, the Department Manager or Nursing Supervisor shall be notified for immediate response and shall attempt to resolve complaint. B. Complaints that are able to be resolved by the Department Manager or Nursing Supervisor require entry into SQSS (Quality/Event Reporting System) as a complaint, under the Occurrence Type " Resolved at Department Level " .

However, the Nurse Manager and the Nursing Supervisor failed to follow through when made aware of an occurrence between a nurse on the night shift and Patient #4. Per nursing progress note for 3/11/14 Nurse#1 assigned to Patient #4 states: " 0040 Nurse went in to do assessment, applied B/P cuff and attempted to listen to apical pulse. PT. states I told you that I did not want you as my nurse. " At 02:06 the same nurse returns to Patient #4 ' s room and describes the patient " ...very hostile ...refused care ...demanded I leave after vital signs " .
The nurse further states s/he notified the charge nurse and Supervisor Patient #4 was requesting another nurse.

Per interview on 3/12/14 at 1:00 PM, the Nurse Manager for the Medical/Surgical Unit confirmed s/he failed to follow-up on the patient ' s concerns and neither the Nursing Supervisor, the charge nurse nor the Nurse Manager completed an event report within the SQSS system as per policy. In addition, although the patient assignment was changed to accommodate Patient #4 ' s request, there was a failure to review the incident, determine why Patient #4 was refusing care from Nurse #1. Per interview on 3/12/14 at 2:45 PM the CNO (Chief Nursing Officer ) confirmed it was his/her expectation a report should have been filed by nursing staff upon being made aware of concerns regarding the care provided by Nurse #1.

Based on record review and interview, nursing staff failed to include in the initial and ongoing patient assessment the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) for a patient with a history of alcohol abuse. (Patient # 9) Findings include:

On 3/10/14 Patient #9 was admitted to the CAH for acute Pancreatitis. The patient has a history of alcohol abuse and admitted to consuming prior to admission " ...a few beers and wine coolers ... " . Although the CIWA can be included in the initial assessment, nursing staff failed to utilize the tool to provide a baseline for potential withdrawal symptoms. The ongoing assessment of Patient #9 also did not include the CIWA until staff noted the patient ' s vital signs were becoming elevated and on the 3rd day after admission nursing staff finally began utilizing the CIWA scoring assessment to determine if Patient #9 required medication to decrease symptoms of alcohol withdrawal.

Per interview on 3/12/14 at 1:30 PM, the Nurse Manager for Medical/Surgical unit confirmed staff had failed to assess Patient # 9 during admission and/or daily using the CIWA tool to determine if Patient #9 was experiencing alcohol withdrawal symptoms and required prescribed medication to help with those symptoms.

Based on record review and confirmed through staff interview the CAH's Patient Visitation policies did not identify the clinical rationale for restricting or limiting visitors in each separate clinical unit and did not address how CAH staff would be trained to assure appropriate implementation of the policies and procedures in an effort to avoid unnecessary restricting/limiting access of visitors to patients. Findings include:

Per review of the CAH policy titled Patient Visitation Rights, dated 12/2013, 'In accordance with Federal rules, it is the policy of Porter Hospital to ensure that each patient enjoy full and equal visitation rights consistent with their preference. The visitation rights are subject to clinically necessary restrictions and limitations...Procedures...4. the right to receive visitors is subject to the restrictions contained in the Visitor Policy with respect to type of patient, regular visiting hours and number of visitors per patient.' Per review of the Visitor policy, dated 02/2013: Medical-Surgical / Special Care: A. Regular hours are 10:00 AM to 8:00 PM. B. No more than two visitors per patient unless deemed appropriate. C. Children under twelve are discouraged from visiting; Pediatrics: Long visits and too many visitors are discouraged. One parent may remain with the patient as much as desired; Obstetrics: Visiting hours are from 10:00 AM to 8:00 PM. Family may also visit at other times at the discretion of the nursing staff. Children under the age of 15 (unless a sibling of the new baby) are not allowed to visit; and Emergency Department: Visiting in the Emergency Department will be restricted to one person per patient in the treatment area, unless otherwise directed by E.R. Staff or Physician. Although the policy identifies some restrictions/limitations in each of the respective patient care units, including the prohibition of visitation by children under the age of 12 in the Medical-Surgical unit and under the age of 15 in the Obstetrics unit it does not clearly identify any clinical rationale for those restrictions/limitations. In addition the CAH policy does not address how staff, who are responsible for the implementation of the policy in each of the respective units, including the PACU (Post Anesthesia Care Unit), will be trained to assure consistent appropriate implementation of the policy, to reduce the incidence of unnecessarily restricting or limiting access of visitors to patients.

The Chief Nursing Officer confirmed, during interview on the afternoon of 2/26/14, that the policies did not included staff training and clinical rationale for restrictions/limitations of visitation privileges.