HospitalInspections.org

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 1 of 7 patients (Patient #7) whose records were reviewed. This resulted in services not being furnished in a consistent manner, and had the potential to result in avoidable, adverse patient outcomes. Findings include:

CAH policies were not developed on when to notify Physicians on changes in patient condition. Additionally, physicians were not notified of change in patient condition for Patient #7.

Patient #7 was a 37 year old female who was admitted to the CAH on 1/22/23, for pyelonephritis. She was discharged from the hospital on 1/25/23.

- Patient #7's medical record included a note documented by RN A on 1/25/23 at 2:07 AM. It included, "Pt tried to walke [sic] to bathroom and collapsed on IV pole."

- Patient #7's medical record included a note documented by RN A on 1/25/23 at 2:53 AM. It included, "Pt stated still felling 'off' which she explained pressure was back in chest."

- Patient #7's medical record included a note documented by RN B on 1/25/23 at 3:18 AM. It included, "Pt reported BLE are weak with tingling sensation. Stated they're 'asleep' Had difficulty walking to the bathroom, 'worse on the left leg'. NOted [sic] L foot drop while walking."

- Patient #7's medical record included a note documented by RN A 1/25/23 at 5:04 AM. It included, "Pt stated chest pressure right on sternum but no pain."

- Patient #7's medical record included a note documented by RN C at 1/25/23 at 7:00 AM. It included, "Pt describes 'tightness in my chest that comes and goes', ..."tingling in my left leg, its difficult to stand on it." Additionally, the assessment by the RN included "new onset weakness/tingling in left leg per pt."

- Patient #7s medical record included a note by RN C on 1/25/23 at 8:09 AM. The note included Patient #7's physician was asked if the RN could discontinue IV fluids. There was no documentation Patient #7's chest pressure, neurological symptoms or collapse were relayed to Patient #7's physician. Patient #7's new symptoms were not relayed to her physician prior to her discharge on 1/25/23 at 3:46 PM.

There was no documentation in Patient #7's medical record that her Physician was notified of the above symptoms on 1/25/23 for chest pressure/tightness, BLE weakness, tingling in left leg, or left foot drop while walking.

Patient #7's physician was interviewed 6/07/23 beginning at 2:00 PM and Patient #7's medical record was reviewed in her presence. When asked if she would expect to be notified of new onset of chest tightness and neurological symptoms she stated, yes if it was new symptoms or change from baseline. When asked if she was made aware of the above new symptoms for Patient #7 prior to discharge she stated "no."

The Director of MSU was interviewed on 6/07/23 beginning at 3:20 PM and Patient #7's medical record was reviewed in her presence. When asked if the CAH had a policy on when to notify the physician of new symptoms for patients, she stated, "we do not have a policy." She stated that nursing judgment is used to notify the physician of a change in status of patients.

The CAH Risk Manager, an RN, was interviewed 6/07/23 at 10:30 AM, and Patient #7's medical record was reviewed in her presence. When asked if Patient #7's physician was made aware of Patient #7's chest pressure and neurological symptoms, she confirmed there was no documentation Patient #7's physician was notified. She stated, "I would expect the RN to call the Physician, even in the middle of the night."

The CAH failed to develop patient care policies on when to notify physicians of new onset symptoms. Additionally, the CAH failed to ensure Physicians were notified of changes in condition for Patient #7.

Based on Grievance reviews and staff interview the hospital failed to provide a written response within the timeline outlined in CAH policy for 2 of 2 patients (Patient #7, #8) who filed a grievance. This resulted in an incomplete resolution of the grievance process.

A CAH policy titled, "Customer Feedback and Grievance Process " last revised 04/2021 was reviewed. This policy stated ...

" On average, the patient/patient ' s representative will be notified of resolution within 7 days. If the investigation for a grievance will not be completed or the issue cannot be resolved within 7 days, the patient/patient ' s representative will be notified, and a written response will be provided no later than 30 days. The grievance response letter MUST INCLUDE the following:
· Name of the hospital contact person
· Steps taken on behalf of the patient to investigate the grievance
· Results of the grievance process
· Date of completion "

This policy was not followed. Findings include:

The hospital complaint and grievance log was requested on 6/06/23 upon entrance conference. Surveyors received a log of complaints, however did not receive a list of grievances. On 6/06/23 beginning at 3:08 PM, the Risk Manager was interviewed and asked how many grievances were there since 1/01/23, she was unable to answer.

Surveyors requested a list of patients with grievances for a second time and not received.

Surveyors requested 7 (Patient #1-7) medical records to review.

1. Patient #7's medical record reviewed was a female admitted 01/22/23 for AKI and pyelonephritis. On 6/06/23 beginning at 3:30 PM, the Risk Manager handed Patient #7's medical record to surveyor and stated, " legal has a copy of her file. " When asked why legal had a copy of Patient #7's record, the Risk Manager reported that the patient is sueing the hospital.

On 6/06/23 beginning at 4:00 PM, the Risk Manager was interviewed as to why Patient #7 was not listed as a complaint or a grievance on the grievance log. The Risk Manager stated, "I just haven't put it in the format." The Risk Manager did state that she copied the chart and sent to legal for review, but did not file as a grievance. Request made again for a complete grievance log.

On 6/07/23 beginning at 8:30 AM, the Risk Manager was asked for the grievance log again, she stated, "we only had two true grievances since January." The Risk Manager confirmed Patient #7 and Patient #8 were grievances. The Risk manager confirmed her initial contact with Patient #7 was on 3/02/23. The Risk Manager stated the issue was unresolved, and a letter was mailed 5/05/23. The letter was sent 64 days after inital contact with Patient #7. The Risk Manager confirmed the Hospital did not follow policy related to grievances and complaints, CAH sent letter after 30 days per CAH policy.

2. Patient #8's grievance reviewed was a male admitted 1/08/23 for perforated bowel post colonoscopy. There was no documentation that Patient #8 was sent a letter for his grievance from the CAH.

On 6/08/23 beginning at 9:30 AM, the Risk Manager was interviewed on the grievance process for Patient #8. The Risk Manager confirmed the initial contact for this grievance was on 1/13/23. The Risk Manager confirmed that the grievance was not resolved and that no letter was mailed to Patient #8. She confirmed the hospital did not follow policy related to grievances and complaints.


The hospital failed to follow their policy related to grievances and complaints.