HospitalInspections.org

Based on grievance log review, policy review, and staff interview the facility failed to follow their own policy in regard to providing the patient's representative written notice of the hospital decision on a grievance brought by the patient's representative.

The findings include:

Review of document titled "Patient Guest Relations/Patient Complaints 1st QTR 2014" contained the following information: "Date: January 17, 2014; Complaint: "Daughter was not satisfied with the way the patient was transferred to ICU"; Action: Addressed; Referred: Janlyn."

Facility policy titled "Patient Grievance and Complaint Management", effective date 11/27/12, states, in part "In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. A grievance is considered resolved when the patient and/or patient's representative is satisfied with the actions taken on their behalf." "A grievance/complaint log will be maintained by Risk Management Department (Patient Guest Relations-Del Sol only). The documentation in the log will include the date of complaint, location, summary of issue, how the issue was addressed, date resolved, and response to complainant, and the individual responding to the grievance."

Interview with the director of risk management, nurse director of the nursing unit, and assistant chief nursing officer on 4/29/14 and 5/1/14 confirmed the above findings and as of this date no written notification has been sent to the complainant per hospital policy on complaint resolution.

Based on medical record review, policy review, and staff interview, data in the patient medical record contained information written by different staff members under the authentication of a single staff member.

The findings include:

Review of medical record for patient #1 on 4/30/14 revealed the 0800 entry on the patient by staff #5 entered at 2127 had data from assessments done on the patient throughout the day on 4/30/14 and contained inaccurate data for the period staff #5 was documenting at 0800. These include lung assessments for the patient, ventilator settings for the patient, and orientation and responsiveness of the patient even though at 0800 the patient was on oxygen per nasal cannula and was not on the ventilator.

Facility policy titled "Assessment/Reassessment" states, in part "All assessments/reassessments are documented in the patient's medical record. The medical record serves as a mechanism for communication and addresses the patient's care/treatment needs, response to treatment, and continued care requirements as appropriate."

Interview with the assistant chief nursing officer on 4/30/14 and 5/1/14 confirmed the above findings and she confirmed the charting for 0800 by staff #5 contained data for the ventilator settings and the patient was not on a ventilator at 0800 while a patient on the medical floor.

Failure to document nursing assessments on a patient in a timely manner delays the communication of patient information and the continuity of care for the patient.

Based on medical record review, policy review, and staff interview the facility failed to ensure they had physician orders for the administration of oxygen therapy.

The findings include:

Review of medical record for patient #1on 4/29/14 revealed there were no admitting orders for oxygen therapy for the patient and no orders for maintenance of an oxygen saturation level for the patient receiving oxygen therapy.

Facility policy "Oxygen Therapy Protocol" states, in part "Oxygen should be considered as a drug and therefore requires an order from a physician or physician's assistant. Oxygen should be prescribed to achieve a target saturation range. Those who administer oxygen will monitor the patient and keep within the target saturation range, unless specific guidelines have been set by physician."

Interview with the assistant chief nursing officer confirmed there was no order for oxygen administration in the patient medical record and the patient was on oxygen therapy since admission to the facility.