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Based on record review and interviews, the hospital failed to ensure the hospital policy was followed for resolution of a grievance for 1 of 1 patient grievance reviewed from a total of 7 sampled patients (#2). Findings:

Review of Patient #2's medical record revealed she presented to the emergency department on 02/24/10 at 11:42pm with complaints of abdominal pain. Further review revealed a telephone call was placed to S2's surgeon, S1, the case was discussed with the surgeon on-call S20, and Patient #2 was admitted.
Review of the RN assessment dated 02/25/10 revealed Patient #2 arrived on the inpatient unit on 02/25/10 at 3:22am.
Review of "Miscellaneous Notes Form" documented by RN (registered nurse) S24 revealed the following events:
02/25/10 8:20am Called Physician S1's office; left message; awaiting call back regarding pain med (medication);
02/25/10 9:10am "Still no call back from Physician S1. Talked to (name of staff at office), She stated, "I will page him again"; Awaiting call back";
02/25/10 10am Paged House Supervisor regarding issue with Physician S1. Physician S1 stated, "I don't want anything to do with this patient call Physician S3". Physician S1 then hung the phone up on nurse. Nurse called Physician S2 who is the on call physician for Physician S3. Physician S2 stated, "Pain medicine and anxiety medicine should be ordered by Physician S1.
Nurse explained to Physician S2 that Physician S1 didn't want anything to do with the patient. Physician S2 stated, "I will not be able to get there till the afternoon". House supervisor and Charge Nurse aware".
02/25/10 10:20am House supervisor talked to Physician S1's secretary and he is supposed to come see the patient in 30 minutes, will F/U (follow up)".
02/25/10 12:38pm Pt (patient) and pt's mother upset regarding Physician S1's attitude. Paged House Supervisor again and let her know that Physician S1 has not shown up. She stated, "I'm calling him back". Will F/U.
Review of the "Miscellaneous Notes Form" documented by Director of Administrative Services S10 on 02/25/10 at 1314 (1:140pm) revealed "Spoke with Physician S1 in surgery, states he had ordered for pt to be transferred to Physician S3. I informed him Physician S2 is on for Physician S3 and is unable to see pt until later and that I was told Physician S1 was going to see pt by 11am. States he is in surgery and will call Physician S2 himself. States he was never informed pt was back in hospital however nurse caring for pt had called office since early am and I spoke with Physician S20 at 10:30am who said she had informed Physician S1 of pts admit. Recalled Physician S1 and was told Physician S2 will see pt and transfer service to Physician S3. Informed pt and mother".
Review of "Miscellaneous Notes Form" documented by RN S24 on 02/25/10 at 3:00pm revealed "Pt stated, "Please unhook me, I'm leaving on my own". Physician S1 and Physician S2 saw pt and explained that the x-ray didn't show a bowel obstruction. Pt. decided to leave the hospital on her own. Pt was aware that Physician S4 was consulted but still wanted to leave. Pt signed AMA (Against Medical Advice) form and left hospital with mother. Physician S1 notified".

Review of the DOERS (Dynamic Online Event Reporting System) "Event Information", submitted by Director of Administrative Services S10, revealed the following: event initiation date and time: 02/25/10 1709 (5:09pm); event initiated by: Director of Administrative Services S10; nature of event: dissatisfaction; event date: 02/25/10; event time: 1500 (3:00pm);brief description of event: pt and mother upset that nurse called Physician S1 ' s office at 8:20am and 9:10am for pain unrelieved by meds (medications) already ordered. Director of Administrative Services S10 was called due to MD (medical doctor) comment that he didn't want anything to do with this pt and to change to Physican S3's service. When Physican S1's office was called at 10:00am, she was told pt would be seen in 30 minutes. After time passed, Physician S1 was called in surgery. He was unable to see pt and phoned Physician S2 (on for Physician S3) to see pt. Pt and mother was kept apprised of all calls. Approx. (approximately) 3:00pm, pt was seen by Physician S1 and Physician S2 and then pt left AMA (against medical advice).

Review of the documentation presented by the hospital of the investigation of the grievance revealed the following:
03/10/10 by Medical Staff Secretary S25 - "concern reviewed by Medical Director. Sent e-mail to initiator of concern for pt name to further investigation".
04/28/10 by Medical Staff Secretary S25 - "no response from initiator. Case was managed appropriately".
Further review revealed no documented evidence of an investigation according to hospital policy to include notification of the physician involved, documentation in DOERS the actions taken to address the grievance, and a written response to the patient.
In a face-to-face interview on 07/21/10 at 10:15am, Director of Organizational Effectiveness S7 indicated that complaints/grievances related to physicians were investigated by the Medical Staff.

In a face-to-face interview on 07/21/10 at 10:45am, Medical Director S11 confirmed the investigation of Patient #2's grievance was not conducted. He indicated a request was made for the patient's name, so the medical record could be obtained, but a response was not received. He further indicated there were personnel issues within the Medical Staff department at the time, and this grievance "fell through the crack".

Review of the hospital policy titled "Patient Issues/Grievances", last revised 08/07 and submitted by Director of Organizational Effectiveness S7 as their current policy for the grievance process, revealed, in part, "...The hospital has a process for prompt resolution of patient grievances ... A guest is any patient, family member or visitor ...A patient "grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. ...B. Receiving Verbal or Written Issues/Grievances 1. Any Team Member may receive a complaint verbally or in writing from Guests or their representative. 2. The team member receiving the complaint completes a Dynamic Online Event Reporting System (DOERS) .... Any issue/concern involving a member of the Medical Staff should be documented in DOERS and forwarded to the Medical Staff office for review and follow-up. It is the responsibility of the Medical Staff office to investigate, notify the involved physician, document in DOERS the actions taken to address the complaint and provide a written response to the Guest in accordance with Section C.6 and 7 below ...C. Addressing Issues/Grievances ...6. The Grievance is resolved in a timely manner. a) If the Grievance is resolved within 7 days, Guest Services will send a written response to the Guest. ... b) If unresolved within 7 days Guest Services will send a written response outlining the continued investigation and a final determination will be forwarded to them within 30 days. ...7. Written responses shall include ... a) A brief summary of the grievance investigated; b) The steps taken to investigate the grievance; c) The results and date of conclusion of the investigation; d) The name and telephone number of the responsible hospital representative so the guest can contact them if further issues arise ...".

Review of the hospital policy titled "Concern Regarding A Physician", last revised 10/07, revealed, in part, "...Concerns regarding a physician may be submitted by way of a Guest Satisfaction Survey, DOERS report, or any other written communication by ant patient, visitor, team member or member of the medical staff. Patient Concerns: 1. Submitted patient concerns are promptly routed to the Medical Director who will be responsible to investigate and respond directly to the complainant within seven (7) working days. If unable to do so, the complainant will be notified by Guest Services that additional time is required and a written response will be given within thirty (30) days. ... 3. The Medical Staff office shall document their review of the concern, timely send a letter to the patient responding to the concern, and retain a copy in its files. If the Medical Staff office receives the complaint via a DOERS report, the Medical Staff shall also document in the comments sections when the issue has been addressed. ...D. Adverse information or actions taken in response to a concern will be entered into a medical staff members credentials file pursuant to Medical Staff Bylaws ...".

Based on medical record review and interview, the hospital failed to ensure the medical staff followed the medical staff bylaws when transferring a patient from the care of the admitting physician to another staff member for 1 of 7 sampled patients (#2). Findings:

Review of Patient #2's "Physician Order Sheet" revealed a telephone order from Physician S1 received on 02/25/10 at 1450 (2:50pm) by Registered Nurse S24 to "transfer admitting to Physician S3". Further review revealed no documented evidence of an order covering the acceptance of Patient #2 by Physician S3.

In a face-to-face interview on 07/20/10 at 11:45am, Physician S3 could offer no explanation for not writing an order of acceptance of the transfer of Patient #2.

Review of the Medical Staff Bylaws, last revised 03/24/10 and presented by Director of Organizational Effectiveness S7 as the hospital's current medical staff bylaws, revealed, in part, "...General Responsibility For And Conduct Of Care ... Transfer of Responsibility When primary responsibility for a patient's care is transferred from the admitting or current attending practitioner to another staff member, an order covering the transfer of responsibility and acceptance of the same must be entered upon the order sheet ...".

Based on patient medical record review and interviews, the hospital failed to ensure a registered nurse supervised the patient's care for a change in condition for 1 of 7 sampled patients (#6). Findings:

Review of Patient #6's medical record revealed an admit date of 04/19/10 with a diagnosis of small bowel obstruction. Further review revealed a "constipation assessment" was completed on 04/25/10 at 1437 (2:37pm) by RNA (registered nurse applicant) S22. Review of the assessment revealed the following: Status: potential; Related To: Constipation; Expected Outcome: Improved bowel function; Abdomen Description: Rounded; Bowel Sounds All Quadrants: Hypoactive; Passing Flatus: no documented evidence yes or no was checked; Constipation Interventions: no documented evidence any of the choices were selected, which included encourage fluids, fluids restricted, encourage ambulation, ambulation restricted, laxative/stool softener given per order, notified MD (medical doctor).

Review of Patient #6's "Results For Stool Count" revealed no documented evidence of a stool count for 04/25/10. Review of the "Intake and Output Flowsheet" revealed no documented evidence of a stool output for 04/25/10.

In a face-to-face interview on 07/20/10 at 1:30pm, RN (registered nurse) Nurse Analyst S14 confirmed there was no documented evidence in Patient #6's medical record that RNA S22 had reported the lack of a bowel movement for 3 days to the RN and the physician, and there was no documented evidence of an intervention by RNA S22 with the outcome.

In a face-to-face interview on 07/21/10 at 9:25am, Director of Organizational Effectiveness S7 indicated the hospital did not have a policy that addressed the actions a nurse should take when completing a constipation assessment. She further indicated the hospital did not have a policy that addressed the measures the nurse should take for a change in a patient's condition, other than what was addressed in the patient assessment/documentation policy.

Review of the hospital policy titled "Patient Assessment/Documentation", last revised 04/08 and last reviewed 03/23/09 and submitted by Supervisor of Clinical Excellence S6 as the hospital's policy for a change in a patient's condition, revealed, in part, "...Purpose: To provide guidelines for the documentation of the nursing process. ... The RN is responsible for analyzing data and planning/evaluating care. ... Reassessments will be completed and documented ...When a significant change occurs in the patient's condition or diagnosis. ... All patient assessments, patient care, and evaluation of the patient's response to care will be documented in the patient's record/chart ...".

Based on review of patient medical records and policies and procedures and interviews, the hospital failed to ensure an individualized patient care plan was developed for alteration in elimination for 2 of 7 sampled patients (#3, #6) and for patient non-compliance for 1 of 7 sampled patients (#6). Findings:

Alteration in elimination:
Patient #3
Review of Patient #3's medical record revealed an admit date of 03/15/10 with the diagnosis of small bowel obstruction.
Review of the "Daily Care Plan Form", completed on 03/16/10 at 1256 (12:56pm) by Registered Nurse (RN) S17, revealed Patient #3 was care planned for pain, potential for injury, alteration in nutritional status, and potential for infection. There was no documented evidence Patient #3's care plan included alteration in elimination.
In a face-to-face interview on 07/19/10 at 10:10am, RN Nurse Analyst S14 confirmed Patient #3 was care planned for pain, infection, injury, and nutrition. In the same interview, Supervisor of Clinical Excellence S6 indicated she would have expected alteration in elimination to be care planned for Patient #3, since she was admitted with a small bowel obstruction.
In a face-to-face interview on 07/19/10 at 10:25am, Supervisor of Orthopedic/Medical/Surgical Unit S18 indicated the computerized care plan for alteration in elimination was triggered by constipation, surgical intervention, diarrhea, and other. She further indicated the nurse would have to choose other, since the patient was not having constipation or diarrhea and had not had a surgical procedure. She confirmed that the alteration in nutrition care plan's outcome did not address bowel function.

Patient #6
Review of Patient #6's medical record revealed an admit date of 04/19/10 with a diagnosis of small bowel obstruction and a chief complaint of abdominal pain.
Review of Patient #6's medical record revealed she was care planned for pain, alteration in urinary elimination, alteration in nutrition, alteration in respiratory function, anxiety, potential for injury, and activity intolerance. There was no documented evidence that Patient #6 was care planned for alteration in elimination until 04/25/10 (6 days after admission for a small bowel obstruction) when she was assessed as not having a bowel movement for 3 days.
In a face-to-face interview on 07/20/10 at 1:15pm, RN Nurse Analyst S14 confirmed Patient #6 should have had alteration in elimination as part of her care plan since admission.

Patient Non-compliance:
Review of Patient #6's medical record revealed an admit date of 04/19/10 with a diagnosis of small bowel obstruction and a chief complaint of abdominal pain.
Review of Patient #6's medical record revealed she was care planned for pain, alteration in urinary elimination, alteration in nutrition, alteration in respiratory function, anxiety, potential for injury, and activity intolerance, and alteration in elimination was added on 04/25/10. Further review revealed no documented evidence Patient #6's care plan was updated for non-compliance to physician orders as evidenced by review of the following documentation from nursing rounds:
04/20/10 at 7:09pm by RN Applicant S22 - "Notified Physician S19 per patient's request of pt's desire to leave unit to smoke. Physician S19 stated that the pt is not to leave the unit per his order. Instructed pt of doctor's order. pt and fmly (family) members insist that she will go down to smoke and no one can stop her. She did agree to try Ativan 1 mg (milligram) IVP (intravenous push) to relieve her nicotine urger, but states "I will go down if I want to. No one can tell me what to do. I'm experienced and have raised four children." Advised pt of risks to health and reasons why it is not in her best interest to leave the unit. Will continue to monitor";
04/21/10 at 12:27am by RN S23 - "Called to room, Patient standing in bathroom doorway, patient's daughter stated "she's trying to go to the bathroom and she wants to go smoke." Patient sat down on toilet and stated "I'm going to do my business and I'm going to smoke." Informed patient and daughter doctor wrote order for patient not to leave the floor and it was not in patient's best interest to be taken off oxygen because her sats (oxygen saturation) on room air were only 86 percent. Patient then stated "I have my rights you, can't denie me of my rights, y'all (you all) are making me mean." Tried second time to encourage patient to stay on floor, daughter then stated "she's not going to listen, I'm taking her to smoke I'm going to see if I can find a wheel chair." Daughter then went and got a wheel chair and encouraged patient into wheel chair, where patient became irritated and yell at daughter "give me my cigarettes and my lighter I want them in my hand." Patient left unit in wheel chair with daughter";
04/25/10 at 9:54am by RN S21 - "...Charge Nurse accompanied MD (medical doctor) to pt's (patient's) room. Pt in wheelchair. Informed pt and daughter that MD was here for evaluation and I asked if I could assist her back to bed. Pt's daughter said "not right now, we're going downstairs to smoke, can you come back in 30 min (minutes)?" MD and I informed pt and daughter that MD was here and was not coming back. Daughter said "fine, don't worry about it then." Pt and daughter proceeded to leave the unit";
04/25/10 at 9:59am by RN S21 -"Observed pt and daughter on smoking patio. Pt visualize eating graham crackers and drinking sprite".
In a face-to-face interview on 07/20/10 at 1:15pm, RN Nurse Analyst S14 confirmed there was no care plan developed for Patient #6 for non-compliance to her orders from her physician.

Review of the hospital policy titled "Planning of Daily Patient Care", last revised 03/23/09 and submitted by Director of Organizational Effectiveness S7 as the hospital's current policy for the plan of care, revealed, in part, "...2. When the patient is admitted, and RN performs an initial nursing assessment within the appropriate time-frame as outlined in the specific scopes of service. ... The information obtained at the time of assessment is transferred to the patient's individual plan of care where it is reviewed and signed off by the RN. Patient's plan of care facilitates the following objectives: a. To ascertain a systematic, concise and organized approach to patient care. ... d. To plan individualized care based upon patient problem identified through assessment. ... 3. Patient care planning/reports are held on each shift and a plan of care is reviewed on each patient... 4. Nursing Plan of Care will be initiated by the nurse. It is reviewed daily and updated as necessary by nurses caring for the patient...".

Based on review of physician credentialing files, review of the Centers for Disease Control (CDS) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, and interviews, the hospital failed to develop a system to ensure all physicians were free of tuberculosis (TB) upon appointment/reappointment and annually thereafter for 1 of 17 general surgeons reviewed (S1), 1 of 59 internal medicine physicians reviewed (S2), and 2 of 17 radiologists reviewed (S5, S13) for annual TB testing. Findings:

Review of the credentialing files for Physicians S1, S2, S5, and S13 revealed no documented evidence that TB testing had been performed upon appointment/reappointment and annually thereafter.

In a face-to-face interview on 07/21/10 at 10:40am, S15, Human Resources Compliance Supervisor, indicated the hospital did not require TB testing for credentialed physicians. She further indicated they were only required to complete the health statement as part of their application/reapplication. S15 indicated only physicians who were hired by the hospital were required to have TB testing, as they were viewed as employees of the hospital.

In a face-to-face interview on 07/21/10 at 10:45am, Medical Director S11 confirmed that the hospital was not requiring credentialed physicians to be tested for TB.

Review of the hospital's Medical Staff Bylaws, last revised 03/24/10, revealed, in part, "...Membership Application ...A membership application form shall be developed and changed as needed by the Medical Executive Committee. The form shall require detailed information which shall include, but not be limited to, information concerning: ... (e) physical and mental health status limited to information which affects quality of care and ability to provide patient care within the Hospital...".

Review of the "Louisiana Standardized Credentialing Application", presented by the hospital as their current application for physician credentialing, revealed, in part, "...Please check the appropriate response to the following questions: If answered YES to any of the questions below, please attach a full explanation on a separate page. ... 8. Do you currently have any ongoing physical or mental impairment or condition which would make you unable, with or without reasonable accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform these essential functions without a direct threat to the health and safety of others?...". Further review revealed, in part, "Practitioner Credentialing Application Authorization And Release Of Information Form... By submitting this application I understand and agree as follows: 1. I understand and acknowledge that, as an applicant for medical staff membership and/or participation status ... I have the burden of producing adequate information for proper evaluation of my ...mental and physical health status...".

Review of Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed in part, HCWs (Health Care Workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: ... Dental staff ... Physicians (assistant, attending, fellow, resident, or intern), including anesthesiologists, pathologists, psychiatrists, psychologists...".