HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to incorporate into the hospital's Quality Assessment and Performance Assessment program the data collected regarding patient grievances/complaints for 2009 to July 2010. Failure to incorporate a review and analysis of patient complaints/grievences into the QAPI program can result in missed opportunities for improved patient care and outcomes. Findings include:

1. Review of the Performance Analysis subcommittee and Performance Improvement committee minutes for 2009 to present revealed no documented review/analysis of patient complaints/grievences.

2. The Vice President of Quality was interviewed on 9/29/10 in the morning and stated the review of patient complaints and grievences has not been done by the Performance Improvement Committee.

Based on review of complaint logs and staff interview it was determined the hospital failed to review, investigate and resolve ten (10) of thirty-three (33) complaints logged as general complaints between 1/1/10 and 8/26/10. This failure creates the potential for a violation of rights for all patients who file a grievance. Findings include:

1. Review of the general complaint log for 1/1/10 thru 8/26/10 revealed ten (10) of the complaints, which were logged in April, May, June and August lacked documentation to reflect the complaint investigations were completed.

2. During interview with the General Counsel in the early afternoon of 9/29/10 these complaints were reviewed and discussed and he agreed with the findings.

Based on review of complaint logs and staff interview it was determined the hospital failed to provide a written notice to thirty (30) of one-hundred twenty-eight (128) total complaints which were logged between 1/1/10 and 8/26/10. This failure creates the potential for a violation of the rights of all patients who file a grievance. Findings include:

1. Review of the hospital complaint logs from 1/1/10 revealed thirty (30) of the one-hundred twenty-eight (128) complaints filed through 8/26/10 reflected the complainants did not receive a written notice.

2. During interview with the General Counsel in the early afternoon of 9/29/10 these complaints were reviewed and discussed and he agreed with the findings.

Based on surveyor observations and staff interview, the hospital failed to ensure the nursing staff follows hospital policy pertaining to the use of side rails as a restraint in one (1) of one (1) patients (Patient #11) observed to currently be in restraints. This has the potential to negatively impact all patient care by creating an environment for increased patient falls and injury. Findings include:

1. United Hospital Center (UHC) Patient Services Policy/Procedure Restraint or Seclusion, last revised 3/10, states in part "...DEFINITIONS: Restraint: A restraint is any manual method, physical and mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...G. Bed Rails: Only the top two rails are used for adults..."

2. UHC Patient Guide, June 2009 Edition, page 8 states in part "...Restraints... As a Medicare provider, UHC is required to follow federal rules that place strict limits on the use of measures that restrict a patient's freedom of movement. This includes any type of restraint unless ordered by a physician to protect a patient from hurting himself or others. Restraints may include medications as well as wrist, ankle, vest restraint and even include lower bed rails if they are being used to restrict a patient's freedom of movement...Lower bed rails will not be up..."

3. During surveyor observations on the Third Floor in the morning of 9/28/10, Patient #11 was observed to be in bed in a Posey vest restraint, as well as having all four (4) side rails in the up position, with a 1:1 hospital sitter at the bedside. The sitter stated the patient had just fallen asleep and had been combative all night. When questioned about the four (4) side rails being up, the sitter stated "They were up when I got here, so I don't know. Probably because he's been confused." The patient's primary nurse was then interviewed and the Registered Nurse (RN) stated the side rails were up because the patient had been confused, combative and trying to get out of bed. The surveyor explained to the RN the use of four (4) side rails for this reason constitutes a restraint and asked if there was a physician's order for such. The RN then reviewed the physician orders and the only order for restraint was for the Posey vest.

Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff obtains a new order when re-applying restraints in one (1) of three (3) restraint records (Patient #3) reviewed. This has the potential to negatively impact all patient care by restraining patients without physician knowledge. Findings include:

1. United Hospital Center (UHC) Patient Services Policy/Procedure Restraint or Seclusion, last revised 3/10, states in part "...DEFINITIONS: Restraint: A restraint is any manual method, physical and mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...Initiation of a Restraint for Non-Violent or Non-Self-Destructive Behavior (Non-Behavioral Health) When less restrictive interventions have been determined to be ineffective in protecting the patient, staff or others from harm. A. Restraint use requires a physician order...D. Continued use of restraint beyond the first 24 hours requires a new order for each calendar day and is based on the physician's examination of the patient...Opportunity for Removal of Restraint for the Non-Violent or Non-Self-Destructive Behavior (Non-Behavioral Health) The physician or RN will assess the patient to determine if the patient meets the criteria for removal of the restraint or seclusion. Patients in restraint for nonviolent/non-self-destructive behavior will be continually assessed for the opportunity for removal of restraints. Restraint should be discontinued when the clinical treatment is discontinued (lines removed, extubated, etc.) or the patient's actions no longer warrant the need for restraint..."

2. Review of the medical record for Patient #3 revealed the patient suffered a Cardiorespiratory Arrest and Cerebral Vascular Accident (CVA) on 7/20/10, was intubated and had a nasogastric tube inserted. The patient was placed in bilateral soft wrist restraints, with physician orders for such, on 7/20/10 at 2045. The restraints were then removed on 7/21/10 at 1930 because the patient was not moving. The patient was then taken off the vent on 7/29/10 at 1411. On 8/3/10 at 0822, the wrist restraints were reapplied with a physician's order timed 0730. Review of the medical record revealed the restraints were then removed at 1130 that morning but then reapplied at 2216 that same night. There is no documented evidence of a physician's order to reapply the wrist restraints. There is documented evidence of physician orders for wrist restraints on 8/4/10 at 0800 and 2050, 8/5/10 at 0600 and 8/6/10 at 0800. The wrist restraints were discontinued on 8/7/10 at 2100.

3. During an interview in the afternoon of 9/29/10 with the VP of Services, the above records were reviewed and the VP agreed with the above findings.

Based on patient observation/interview, medical record review and staff interview it was determined the registered nurse failed to medicate and reassess one (1) of one (1) patients observed and interviewed who indicated he was in pain (patient #9). This has the potential to adversely impact the comfort and care of all patients who experience pain. Findings include:

1. At 0920 patient #9 was interviewed and observed to be grimacing in pain.

2. At 0925 the Charge Nurse was interviewed regarding this patient's pain assessment and pain medication schedule. After reviewing the patient's Medication Administration Record (MAR) she stated the patient had an order for pain medication, as needed, every three (3) hours. She stated his last recorded pain medication was documented as administered at 0141 (nearly eight (8) hours prior). The charge nurse stated the patient's last pain assessment was recorded at 0632 (nearly three (3) hours prior). She stated the medical record reflected at 0632 the patient complained of pain which was rated, by the nurse, as a ten (10) on a scale of 0-10 (with 0 indicating no pain and 10 indicating worst pain). She acknowleged the MAR indicated the patient was not medicated, per orders, for the pain which was documented at 0632. She then stated she would medicate the patient.

3. Review of the medical record for patient #9 revealed a 9/27/10 physician's order for Dilaudid 0.5 mg IV (intravenous) every three (3) hours prn (as needed) for pain.

4. Review of the nursing flowsheet for 9/28/10 at 0632 revealed the registered nurse documented the patient's pain level as ten (10). The record reflected the patient was not reassessed until 0936.

5. Review of the patient's MAR revealed the patient was not medicated for the level ten (10) pain, which was assessed at 0632, until 0929.

6. During the afternoon of 9/28/10 this record was reviewed and discussed with the Nurse Manager. She agreed with these findings. She stated: "the nurse should have medicated the patient for the pain which was assessed at 0630 and reassessed him for the effectiveness of the pain medication in one (1) hour (at approximately 0730).