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Based on interview and document review, the facility failed to inform patients of the final resolution of their grievances in a letter for 2 of 3 patients (P33, and P34).

Findings Include:

P33 submitted a grievance dated 6/22/15. The following was noted: Pt [P33] [FB] called and wanted to speak with ED [emergency department] supervisor about the care [P33] received under doctor while in the ED on 6/2/15 and c/o [complained of] leg swelling and rash. Also had oxygen issues. States doctor said, 'there is nothing we can do, this is a histamine reaction and take Benadryl.' Did not prescribe anything for the symptoms. The next day [P33] saw a provider when being seen in an appt [appointment] for a family member and was prescribed Claritin and told to take Benadryl for 3 days. [FB] wants this reviewed and does not think [P33] should be responsible for the whole ED visit since nothing was ordered. Event resolution: Called pt [patient] at home informed[P33] that case sent to peer review SLL-A verified in an interview on 9/25/15 at 12:37 p.m. a response letter was not sent to P33 within seven days of the grievance to inform them the hospital was still working to resolve the grievance and verified a written notice outlining the resolution of the grievance was not sent to P33, as these steps were not currently a part of the hospital's grievance process.

P34 submitted a grievance dated 8/19/15. The following was noted: "Patient called upset with the care [P34] received at urgent care from doctor...[P34] states that he [Doctor-A] manipulated [P34] knee and hip and since than [P34] is unable to walk or stand. Waiting for patient to call back called and left a message. SLL-A verified in an interview on 9/25/15 at 12:37 p.m. a response letter was not sent to P34 within seven days of the grievance to inform them the hospital was still working to resolve the grievance and verified a written notice outlining the resolution of the grievance was not sent to P34, as these steps were not currently a part of the hospital's grievance process.

The hospital's policy, Patient/Resident Grievance and/or Compliant dated 9/14, instructed, "...Complaints submitted by the patient/resident or his or her representative will require the institution to respond within 14 working days of receipt of the complaint and will be subject to the rules and regulations governing the patient/resident grievance mechanism ..." The Quality and Safety Officer stated on 9/22/15 at 12:30 a.m. that the grievance policy had been updated 6/15, but had not been approved by the governing board.

Based on document review and interview, the facility to develop and maintain current nursing care plans for patient assessed health related interventions for 10 of 36 patients (P9, P12, P19, P22 ,P24, P26, P27, P28, P31, P32) reviewed.

Findings include:

P9's record was reviewed and noted a history and physical note for P9 indicating an admit date of 9/24/15, and diagnoses including acute gastrointestinal bleed, acute blood loss, altered mental status, and atrial fibrillation. A nursing care plan could not be located in the record and on asking the staff for the care plan to review none was provided.

When interviewed on 9/25/15 at 12:15 p.m., the Director of Inpatient Services stated she had looked and could not find a nursing care plan for P9.


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P12 was admitted to the facility following a surgical procedure (Nissen Fundoplication) to repair a hiatial hernia and improve gastroesophageal reflux disease according to the admission form. A Nursing Care Plan for Acute Pain Management had been initiated however, there had been no plan developed for the acute issue of post operative complications, the chronic diseases of obstructive sleep apnea with need for a CPAP (continuous positive airway pressure) machine, depression, obesity and heel pain, and others.

P19 was re-admitted to the facility 6/10/15 with vomiting and decreased urine output just two days after discharge from bowel surgery. A Nursing Care Plan was initiated for Acute Pain Management, but failed to include the acute issue of post operative complications including dehydration, colostomy, abdominal wound vacuum (to allow the abdominal wound to close from the inside).

P22's record revealed a history and physical note for P22 which indicated P22 had been admitted on 9/14/15 with primary diagnoses including shortness of breath due to chronic lung disease, and cardiac concerns. The Nursing Care Plan in place for P22 included decreased cardiac output/cardiac care. However, it did not address shortness of breath due to chronic lung disease.

P24 had a history and physical note indicating P24 had been admitted 9/19/19 with diagnoses of assault to the face and head, and intellectual and physical disabilities. The record indicated P24's disabilities limited the ability to communicate fully. An imaging scan of the head revealed a mildly displaced nasal bone. A Nursing Care Plan was initiated for impaired mobility however, lacked any information regarding potential pain from the displaced nasal bone, or communication disability interventions.

On 9/25/15, at 9:00 a.m. registered nurse (RN)-B was interviewed and explained the care plans were picked by the admitting nurse from a drop down selection box on the computer. RN-B acknowledged P22 & P24's care plans should have addressed their needs related to pain, breathing and communication concerns.

P26 was admitted to the facility on 5/31/15, with left sided weakness according to the admission form. A Nursing Care Plan was initiated to address risk of falls, but failed to include acute issues of agitation and altered mental status, or dehydration.

P27 was admitted to the facility on 5/22/15, after 3 days of vomiting; The Admission Form indicated P27 had a large mass removed from the abdomen on 5/15/15. A Nursing Care Plan was initiated for Acute Pain Management and Risk of Falls however, no Nursing Care Plan had been initiated to include acute issues of bowel obstruction, need for nasal gastric tube (to drain fluids and allow decompression of the bowel), or dehydration.

P28 was admitted to the facility on 7/6/15, after a fall according to the admission form. A Nursing Care Plan was initiated for Acute Pain Management and Risk of Infection however, no plan was established to identify interventions related to acute issues of laceration requiring repair, elevated temperature, or subdural hematoma.

P31 was admitted to the facility on 7/2/15, following total knee arthroplasty (replacement of knee joint) according to the admission form. A Nursing Care Plan was initiated for care of Acute Pain Management however, no Nursing Care Plan had been initiated to address acute issues of post operative complications including swelling.

P32 was admitted to the facility on 6/10/15, with generalized edema according to the admission form. The Nursing Care Plan included Excess Fluid Volume/Fluid Management, however failed to include acute issues of significant coronary artery disease (heart disease) with grafts (replacement of heart circulation) and implanted defibrillator.

On 9/25/15, at 12:00 p.m. the director of nursing stated the facility encouraged the nursing staff to pick only the most relevant Nursing Care Plan issues.

The hospital's Care Plan Policy dated 9/15, included: "A nursing care plan is based on a nursing assessment. Formulates a nursing diagnosis, nursing interventions and nursing activities to achieve positive patient outcomes....Throughout the inpatient stay, the nursing care plan will be updated. Each shift the RN will review the nursing care plans related to the team that she/he leads. The RN revises the nursing care plan as appropriate to meet the changing needs of the patients."

Based on observation, interview and document review, the hospital was found to be out of compliance with Life Safety Code Requirements at CFR §485.623(d). These findings had the potential to affect all patients in the Acute Care Hospital and clinics.

Findings include:

Refer to Life Safety Code deficiencies at regulations: K-0011, K-0029, K-0033, K-0046, K-0050, K-0052, K-0076.

Based on observation, document review, and record review, the facility did not follow the current Centers for Disease Control (CDC)/Food and Drug Agency (FDA) when disinfecting a multi-patient use glucometer device. This affected 1 of 1 patient (P16) observed who utilized a glucometer device and all patients who have blood sugar tested with the multi-use glucometer.

Findings include:

During observation of a blood glucose check on 9/23/15, at 8 a.m. registered nurse (RN)-A used a Stat Strip glucometer to check the blood glucose level of P16 who was a patient in the intensive care unit (ICU). After the glucometer check was completed RN-A wiped the Stat Strip device with an alcohol wipe and returned it to the counter in the ICU. RN-A had been immediately interviewed and asked what she had used to disinfect the glucometer, and she replied that she used an alcohol wipe because that is what the device's manufacturer recommended. RN-A was then asked how many glucometers are used in the ICU and if those glucometers are shared by patients in the ICU. RN-A replied that there were three glucometers in the ICU and they were shared by patients in the ICU.




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There was a Food and Drug Administration (FDA) alert on June 25, 2014, to manufacturers of blood glucose monitoring devices, in regards to a recent hepatitis outbreak from a shared glucose meter, and regulatory changes that were to be put into affect immediately for the cleaning requirements of a shared glucose meter device. This alert was a reminder to an 8/23/10 clinical reminder which had been issued by FDA, Centers for Disease Control (CDC), and Center for Medicare/Medicaid Services (CMS), regarding the risk of transmission from a shared lancing (fingerstick) or glucose meter device. This alert was available on the Internet, and provided to the facility, along with updated Nova StatStrip directions.

An undated Policy and Procedure for Cleaning Nova StatStrip POC (Point of Care) Glucometer indicated the following directions:

"Cleaning / Disinfection of Glucometers as follows;
*All glucometers will be cleaned and disinfected using Clorox Germicidal Wipe, EPA Reg. No. 67619-12, or equivalent.
*A 1-10 bleach solution is also acceptable (1 part bleach to 9 parts water).
*All glucometers that will be shared by multiple patients will be thoroughly wiped with disinfectant and allowed to air dry after every use and between every patient."

The Director of Inpatient Services was interviewed on 9/23/15 at 9:50 a.m. and confirmed that there are three glucometers used in the ICU that are shared by patients in the ICU. Also the Inpatient services director was not aware of the FDA alert issued on June 25, 2014.

Based on interview and document review, the facility failed to ensure History and Physical (H & P) had been completed within 30 days of surgery for 2 of 11 surgical patients (P12, P19).

Findings include:

P12 had a Nissen Fundoplication performed on 5/11/15 however, the last H & P on the medical record was dated 3/27/15 which was 45 days prior to surgery.

P19 had a incision and drainage of abdomen on 8/6/15 however the most recent H & P was dated 5/25/15 which was 73 days prior to surgery.

On 9/25/15, at 12:15 p.m. the surgical services leader verified an H & P was required within 30 days prior to surgery.

The hospital's Pre-Op Assessment Policy last revised 5/13, included a recent history and physical (within 30 days) is documented on each chart before the patient is transferred to the Operating Room for each scheduled case. The H & P requires identification of the patient, the chief complaint, the history of present illness, the past medical/surgical history, allergies, medications, laboratory values, the social history, the family history, a review of systems (physical assessment and discussion of body systems).