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Based on record review and interview, the hospital failed to ensure the grievance process was followed per facility policy for one (Pt #6) of twenty patients.

This failed practice has the likelihood to place all patients at risk of poor resolution of grievance, creating an unsafe environment and unresolved patient care concerns.

Findings:

A review of a hospital policy titled, "Patient Complaint/Grievance Resolution," read in part, "Patients, their family, or patient's representative may contact any OUM employee to express their complaint." and the employee "Completes feedback module in RL Solutions."

Pt #6
A review of the "Complaints and Grievance" log provided to surveyors on 07/20/20 does not include this patient. A review of documentation showed Staff Z received an email 07/16/20 from the patient's family member stating the intent to file a formal grievance.

On 07/22/20 Staff K presented the surveyor with a grievance that was entered in RL Solutions 07/21/20 after risk received the grievance via email 07/20/20. Per documentation the family member only obtained the risk email address after corresponding with the hospital's Facebook page and receiving a telephone number to call.

The family member documents in the email sent to Staff Z and risk that she attempted "calling the floor manager and chaplains but kept getting disconnected."

On 07/22/20 at 09:39 am Staff X stated whoever receives a call regarding a complaint or grievance can enter it into RL Solution.

On 07/22/20 at 11:25 am Staff Z stated she had recently received an email regarding a grievance/complaint regarding Pt #6 and forwarded the email to Staff F and X. Staff Z stated she was not familiar with the grievance process and had only become aware of it after hearing nursing staff discuss the process. Staff Z stated she was not trained on the grievance/complaint process.

On 07/22/20 at Staff K stated that she believes a complaint or grievance should be entered into RL Solutions within 24 hours. The grievance from Pt #6 family member wasn't entered into RL Solutions within 24 hours of being received 07/16/20 by Staff Z.

Based on record review and interview the hospital failed to follow grievance procedures for one (Pt #6) of twenty patients.

This failed practice has the likelihood of visitor, staff, and patient or family concerns being unresolved and no improvement to processes being made.

Findings:

A review of a hospital policy titled, "Patient Complaint/Grievance Resolution," read in part, "Patients, their family, or patient's representative may contact any OUM employee to express their complaint." and the employee "Completes feedback module in RL Solutions."

Documentation showed that a family member had been attempting to contact the hospital via telephone "07/15/20, 07/16/20 and 07/17/20 to inquire about the grievance process and to document a formal grievance." The family member then sent an email to staff on 07/16/20 with no documented follow up by staff. The family member only obtained the risk email address after corresponding with the hospital's Facebook page and receiving a telephone number to call. The family member emailed Risk 07/20/20 and a grievance was entered into RL Solutions 07/21/20.

On 07/22/20 at 1:25 pm Staff K stated that it didn't appear policy and procedure was followed when the email was received 07/16/20.

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Based on record review and interview, the hospital failed to ensure:
1. reassessment of pain medication administration for two (Patient #2 and #5) of 20 patients
2. assessment of wounds for three (Patient #6, #14, and #17) of 20 patients
3. care was provided as ordered by the physician for one (Patient #6) of 20 patients

This failed practice has the likelihood to place patients at risk of unrecognized clinical condition, delayed intervention and ineffective treatment outcomes.

Reassessment of Pain

Review of a policy titled "Pain Management and Opioid Naivety Guidelines" read in part, "Nurses will reassess patients approximately 30 minutes post IV push opioid."

Patient #2

Review of a document titled, "Medication Discharge Summary" showed Dilaudid 1mg IV was administered for pain on 07/01/20 at 7:41 PM and pain was reassessed on 07/01/20 at 10:35 PM (2.5 hours late).

On 07/21/20 at 10:09 AM, Staff T reviewed the medical record for Patient #2 and stated the patient's pain should have been reassessed 30-60 minutes later to evaluate the effectiveness of the pain medication.

Patient #5

Review of a document titled, "Medication Discharge Summary" showed Sublimaze 25 mcg IV was administered for pain on 04/11/20 at 00:33 AM and pain was reassessed on 04/11/20 at 2:37 AM (1.5 hours late).

On 07/21/20 at 1:50 PM, Staff E reviewed the medical record for Patient #5 and stated the pain reassessment was late.

Assessment of Wounds

Review of policy titled "Guidelines for Skin and Wound Care" read in part, "Wounds will be assessed..with shift assessments. The following parameters will be assessed on all wounds ...anatomical location of the wound, description of the wound bed, presence/absence of drainage, condition of dressing if not removed at time of assessment and reason wound not visualized."

Patient #6

Review of a document titled "Critical Care Adult Shift Assessment" dated 06/12/20 at 7:00 AM showed wound present under field collar orthotic device with no description of the wound.

Review of documents titled "Operative Reports" showed the following surgical procedures were performed on 06/12/20:
1. Intramedullary nail fixation right femur
2. Open reduction internal fixation right malleolus
3. Closure of wound right ankle
4. Closure of wound right lower leg
5. Laparotomy
6. Liver resection
7. Cholecystectomy
8. Wound vacuum placement
9. Angiogram with sheath to right groin

Review of a document titled "Critical Care Adult Shift Assessment" dated 06/12/20 at 10:00 PM showed no documentation of surgical wounds or wound vacuum device and showed documentation no surgical wounds were present.

Review of documents titled "ICU/CCU Reassessment" dated 06/13/20 at midnight and 4:00 AM showed no documentation of surgical wounds and showed documentation no surgical wounds were present.

On 07/22/20 from 10:14 AM to 10:48 AM, Staff W reviewed the medical record for Patient #6 and stated:
1. Wounds were to be described so it could be known whether they were getting worse or not.
2. The nurse should have described the wound under the orthotic device.
3. The surgical wounds and types of dressings should have been documented for the purpose of monitoring drainage.

Patient #14

The clinical record was reviewed. The documentation showed abrasions to right gluteus, right knee, multiple abrasions right lower extremity and; left open tib/fib fracture with degloving injury to left heel and abrasions to the left elbow. Nursing assessments dated 07/20/20 through 07/22/20 documented a wound to the left tibia site had a Wound Vac and an additional wound site to the left lower extremity was covered by a dressing, neither site was assessed. The documentation showed the right lower extremity had a splint device in-place but documented no wound sites or dressing materials were in-place. The documentation did not show wound site assessment or care was conducted to any of the identified wound sites by the nursing, medical, or physical therapy staff.

On 07/22/20 at 9:35 a.m., Staff V stated there was no documentation of wound care to the wound sites. Staff V further stated nursing should have assessed all of the patients wound sites every shift and reported to the physician if there were no orders to provide wound care.

At 10:30 a.m., Staff E stated orthopedic service physicians manage patient Wound Vac's themselves; will have physical therapy manage the wound care; or will write orders for the nursing staff to perform wound care. Staff E further stated nursing staff were required to assess wound sites unless there was a physician order not to remove a dressing and the nursing staff were required to document the reason why a wound site was not assessed.

Patient #17

The clinical record was reviewed. The documentation showed no physician orders for wound care to an open left lower extremity ankle fracture. The documentation did not show wound site assessment or care was conducted by the nursing, medical, or physical therapy staff.

On 07/22/20 at 11:45 a.m., Staff E stated there were no physician orders for wound care to the open left ankle fracture wound site.

At 12:45 p.m., Staff V stated the nursing assessment notes from 07/20/20 through 07/21/20 showed no documentation that the wound site was assessed or that care had been completed.

Care Provided as Ordered

Patient #6

Review of a physician order dated 06/12/20 at 10:20 AM showed patient's chest tube was to be set to water seal.

Review of a document titled "Critical Care Adult Shift Assessment" dated 06/12/20 at 10:00 PM showed documentation the patient's chest tube was not set to water seal.

Review of documents titled "ICU/CCU Reassessment" dated 06/13/20 at midnight and 4:00 AM showed no documentation of chest tube settings and no documentation of change from the 06/12/20 10:00 PM assessment.

Review of a physician order dated 07/03/20 at 3:20 PM read in part, "Physical Therapy Wound Care. Plan to see patient for wound care: DAILY."

Review of a physical therapy note dated 07/04/20 at 1:52 PM showed patient was seen by physical therapy for wound care on 07/04/20 and read in part, "Wound Care Treatment Plan. Plan to see patient for wound care: M/W/F." There was no physical therapy note to show patient received physical therapy wound care on 07/05/20.

On 07/22/20 at 10:24 AM, Staff W reviewed the medical record for Patient #6 and stated the chest tube should have been set to water seal per physician's order.

On 07/23/20 at 8:43 AM, Staff E reviewed the medical record for Patient #6 and stated:
1. "We had a miss."
2. The physical therapist should have put in an order for a doctor to co-sign the decrease in frequency of wound care provided by physical therapy.

Based on record reviews and interviews, it was determined the hospital failed to ensure physician orders for wound care were obtained for two (Patients #14 and #17) of 20 patients.

This failed practice had the potential to effect all patients with active wounds causing the likelihood of experiencing negative physiological or psychological outcomes.

Findings:

Patient #14

The clinical record was reviewed. The documentation showed abrasions to right gluteus, right knee, multiple abrasions right lower extremity and; left open tib/fib fracture with degloving injury to left heel and abrasions to the left elbow. The documentation showed no physician order for care of the wound sites to the right lower extremity, right elbow, left elbow or left posterior lower leg. The documentation did not show wound care was conducted by the nursing, medical, or physical therapy staff to any of the identified wound sites.

On 07/22/20 at 9:35 a.m., Staff V stated there was no physician's order for wound care to the right lower extremity sites, right elbow, left elbow, or left posterior lower extremity. There was no documentation of wound care to the wound sites.

At 10:30 a.m., Staff E stated orthopedic service physicians manage patient Wound Vac's themselves; will have physical therapy manage the wound care; or will write orders for the nursing staff to perform wound care.

Patient #17

The clinical record was reviewed. The documentation showed no physician orders for wound care to an open left lower extremity ankle fracture. The documentation did not show wound care was conducted by the nursing, medical, or physical therapy staff.

On 07/22/20 at 11:45 a.m., Staff E stated there were no physician orders for wound care to the open left ankle fracture wound site.

At 12:45 p.m., Staff V stated the nursing assessment notes from 07/20/20 through 07/21/20 showed no documentation that the wound site was care had been completed.