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Based on policy and procedure review, grievance file review, and staff interview the hospital staff failed to describe the steps taken on behalf of the patient to investigate the grievance or the outcome of the investigation for 1 of 2 grievance files reviewed (File #1).

Findings included:

Review on 05/3012018 of the "Patient Grievance Management Policy", revised 11/2016, revealed "SUMMARY STATEMENT" This policy sets forth the procedure for appropriately identifying and promptly resolving patient grievances ... DEFINITIONS "Patient Grievance" is a written or verbal complaint ....by a patient ....regarding (1) the patient's care ...Examples of "Patient Grievances" include: 1. All written complaints (whether from an inpatient, outpatient, discharged patient .... regarding patient ...5. A complaint identified during a post call, including patient satisfaction surveys when the patient requests resolution or provides a written complaint. 6. All post-discharge complaints to the (Hospital) Customer Care Line, and any similar post-discharge complaints. 7. Any complaint in which a patient or patient's representative requests the complaint be handled as a formal complaint or grievance or requests a response from the facility. ..."

Review on 05/31/2018 of the "Patient Complaint and Grievance Management Policy", revised 04/2018, revealed "Summary Statement This policy sets forth the procedure for teammates to implement service recovery to address complaints or other spoken and unspoken patient needs. ...This policy also set forth the procedure for appropriately identifying and promptly resolving patient complaints and grievances ... Definitions ... Complaints include: * An expression of displeasure with a process or person by the patient, ...* An expression of dissatisfaction with some aspect of care / service by a patient. ...Grievance: A formal or informal written or verbal complaint about patient care that is not resolved at the time of the complaint ... Examples of "Patient Grievances: include: * All written complaints regarding abuse, neglect, patient harm, or compliance with Conditions of Participation (COPs) ..."

Review on 05/30/2018 of the "Review and Resolution of Complaints ..." policy, revised 09/13/2016, revealed " ...Time Frame for Resolution ...the Privacy Complaint Committee must investigate the underlying circumstances ... Unless the complaint is anonymous, ...the Privacy Complaint Committee must provide a written response to the individual who submitted the privacy complaint containing the following information: ... "The name of the contact person at the Regional Corporate Responsibility Office or at the (named entity) who will answer questions relating to the investigation and resolution of the privacy complaint; "A general description of the steps taken to investigate the privacy complaint; and "An explanation of the (named entity's) resolution regarding the privacy complaint. ..."

Review of Grievance File #1, on 05/29/2018, revealed the grievance was received on 05/07/2018. Review revealed "... Did not listen, Insufficient info (information) to patient, Poor Communication between staff." File review revealed an acknowledgment letter, dated 05/10/2018, that stated "... I am writing in response to the letter received on May 7, 2018. We appreciate your willingness to take the time to communicate with us. We have tried to reach you on three different occasions and were unsuccessful in speaking with you. If you would like to discuss your concern further, please contact me. We apologize we did not meet your expectations. Please contact me if I can be of further assistance. Providing great care to the patients in this community and the surrounding communities is an important component of our mission. ...Guest Relations Specialist (GRS) name ..." Letter review did not reveal a description of the steps taken on behalf of the patient to investigate the complaint nor the outcome of the investigation.

Interview with the Accreditation Manager (AM) and Director of Patient Safety (DPS), on 05/30/2018 at 1300, revealed the grievance response letter did not include all requirements. Further interview revealed policy was not followed.

Interview on 05/31/2018 at 1345 with the AVPPCS revealed "I'm going to go ahead and throw myself on sword. A lot more work needs to be done" with the grievance process." Interview revealed attempts to contact the complainant were made 05/08/2018 at 1723, 05/09/2018 at 1356, and 05/10/2018 at 1207 without success. Interview revealed an "Unable to contact letter sent after 3 attempts" and the "Case Status" was noted as "Closed". Interview revealed after three attempts were made to contact the patient with no return correspondence, it was decided that was sufficient and the case was closed. Interview revealed "Patient Grievance Management Policy..." and "Patient Complaint and Grievance Management " policies were not clear and open to interpretation and that they needed to be reviewed for clarification. Interview revealed hospital polices regarding management of a formal complaint was not followed.

Based on hospital policy and procedure reviews, medical record reviews and staff interviews the hospital nursing staff failed to assess and monitor 1 of 9 patients (Patient #10).

Findings included:

Review of hospital policy titled "Medication Administration" revised 04/2018 revealed, "...XII. Documentation ... C. 5. For PRN (as needed) medications, document drug, dose, route, and reason given with a patient response, within one hour..."

Review on 05/29/2018 of the hospital policy titled "Blood Pressure Assessment" revised: 05/18/2018 revealed, " * Routine vital signs (T [temperature], P [pulse], R [respirations], BP [blood pressure], and oximetry [percent of oxygenation in the blood stream], if ordered) shall be recorded at least twice daily unless there is an overriding Provider order, the patient is post-op, or patient protocols require otherwise. * RN (Registered Nurse) to notify Provider of abnormal values based on patient's clinical condition and age....Documentation: ... Record the name of any practitioner notified about blood pressure results, the date and time of notification, prescribed interventions, and the patient's response to those interventions."

Open medical record review on 05/29/2018 of Patient #10 revealed, a 62 year old female was admitted to the hospital on 05/24/2018 with a chief complaint of abdominal pain and rectal bleeding. Medical record revealed vital signs upon admission were 98.9, 100, 20 and 121/56. Review of the history and physical revealed Patient had a diagnosis of abdominal pain and rectal bleeding. Review of thepatient's home medication list on admission revealed 3 medications for blood pressure control (Amlodipine 10mg by mouth daily, Carvedilol 3.125 mg by mouth twice a day and Clonidine 0.2 mg by mouth twice a day. Review of the "Admission Medication Reconciliation list" (a list of patients home medications) revealed, Carvedilol 3.125 mg by mouth twice a day was the only medication continued initially. Further medical record review revealed on 05/27/2018 at 1016 MD #3 entered an order for Clonidine 0.1 mg every 12 hours scheduled for 0900 and 2100, then on 05/28/2018 at 0941 MD #3 entered an order was placed for Clonidine 0.2 mg (every 12 hours, 0900 and 2100) twice a day by mouth.

- BP on 05/26/2018 at 0822 = 152/112
- BP on 05/26/2018 at 1934 = 153/102 (11 hours later)
- BP on 05/27/2018 at 0821 = 168/92 (11 hours and 13 minutes later)
- BP on 05/27/2018 at 2020 = 132/95
- BP on 05/28/2018 at 0742 = 152/93
- BP on 05/28/2018 at 1824 = 150/104
- BP on 05/29/2018 at 0546 = 146/104 (12 hours and 48 minutes later)
- BP on 05/29/2018 at 0713 = 135/71 (1 hour and 27 minutes later)
Record review failed to reveal documentation of physician notification of elevated blood pressures and the effectiveness of the antihypertensive medications per policy.

Interview on 05/30/2018 at 1115 with CP #1 (Care Partner/CNA), during review of the medical record confirmed on 05/26/2018 the elevated blood pressure was 153/102, the CP stated, "The RN was notified at the start of shift. About an hour after I think I rechecked the blood pressure." Interview revealed CP#1 could not recall the name of the RN she informed of the elevated BP. During the interview the CP was unable locate the recorded documentation of notification to the RN. Interview failed to reveal documentation of RN notification per policy. The interview confirmed there was no documented notification of the RN being informed of an elevated blood pressure or notification of the provider.

Interview on 05/30/2018 at 1120 with the Clinical Nurse Educator (CNE #2) revealed, "There is a place for the Care Partner to type in notification to RN of blood pressure or vital signs being outside of normal range, documented as high or critical. It is the expectation that the Care Partners notify the RN of elevated BP or vital signs outside of normal range limits and document the notification in the computer." Interview during record review revealed normal diastolic range was 60-90 mmHg, and normal systolic range was 110-135 mmHg per protocol. Interview revealed blood pressures that fall outside of the reference range should be reported to the provider. The interview confirmed there was no documented notification of the RN being informed of an elevated blood pressure or notification of the provider.

Interview on 05/30/2018 at 1130 with MD#3 revealed, "I started slow to resume some of the blood pressure medications. I chose Coreg 3.125 mg to continue because it was the safest drug to continue. ...I do not recall getting any notification from nursing staff of blood pressures being elevated as high or critical values. It is my expectation of nursing staff to notify me of blood pressure being elevated high/low or critical in any way." MD#3 reveiwed the documented blood pressures and confirmed that the expectation would be to notify the provider of abnormal vital signs. The interview revealed nursing staff was expected to notify the provider of abnormal vital signs.

Interview on 05/30/2018 at 1140 with CP #2 revealed, the elevated blood pressure would require RN notification. Interview revealed the CP#2 obtained the blood pressure on 05/26/2018 at 0822 as 152/112 with no documented notification of RN nor a repeat of the elevated blood pressure. "If the nurse wanted me to repeat the vital signs at any time she would let me know when to repeat it. I did let the nurse know about the vital signs being out of normal range but I did not document anywhere that it was communicated to the RN." Interview revealed, she verbally informed the RN of the elevated blood pressure outside of normal range. Interview revealed no documentation of reassessment for elevated blood pressure. She failed to document notification in the medical record.

Based on hospital policy and procedure reviews, medical record reviews and staff interviews nursing staff failed to ensure nursing care plans were initiated as per policy for 1 of 9 patients (Patient #10).

Findings included:

Review of the hospital policy titled "Interdisciplinary Care Planning and Documentation [IPOC]" revised 10/17 revealed, "POLICY...is individualized to meet the patient's unique needs. The first step in the process includes creating an initial plan for care, treatment, and services that is appropriate to the patient's specific assessed needs. ...the plan is maintained and revised based on the patient's response. 5. Documentation ...b. Nursing Component The RN develops the goal (outcomes) and interventions and initiates the care plan; the RN reviews, modifies, changes, or updates the care plan as needed; the RN documents that the patient goals/outcomes are met.

Open medical record review on 05/29/2018 of Patient #10 revealed, a 62 year old female was admitted to the hospital on 05/24/2018 with a chief complaint of abdominal pain and rectal bleeding. Review of the History and Physical on 05/24/2018 revealed "... Impression and Plan ...Pain control..." Review revealed Patient #10 was ordered and received (acetaminophen 600 mg po (by mouth) PRN (as needed) q 6 hr (every 6 hours), hydrocodone-acetaminophen 1 tablet po PRN q 4 hr, and morphine 1mg IV (intravenous) PRN q 8 hr) pain medications during her admission. However the IPOC did not address pain. Review revealed nursing staff failed to initiate a Plan of Care with treatments; goal; outcomes; and target dates for Pain.

Interview on 05/31/2018 at 1300 with Clinical Nurse Educator (CNE) #2, during review of the IPOC, revealed "It is used to help clinical staff direct the focus of patient care. It is the expectation of the hospital that if a patient comes in with abdominal pain then pain should be included on the IPOC." Nursing staff initiate the IPOC on admission and it drives the care to be provided to the patient. Interview failed to reveal an IPOC with nursing treatments; goal; outcomes; and target dates for Pain.

Based on hospital policy and procedure reviews, medical record reviews and staff interviews nursing staff failed to ensure vital signs were obtained per policy and to follow documentation requirements for blood administration for 1 of 4 patients (Patient #9).

Review of the hospital policy titled "Blood-Blood Component Administration" revised: 04/2018 revealed, "IV. INTERVENTION ... Minimal vital signs T, P, R, BP (and oxygen saturation if indicated) requirement: Baseline vital signs are obtained within 30 minutes prior to starting the transfusion...10 - 15 minutes after starting the transfusion... . Within 60 minutes after the transfusion is stopped."

Open medical record review on 05/29/2018 of Patient #9 revealed, a 43 year old female presented to the Emergency Department (ED) on 05/26/2018 at 0400 by way of emergency medical transportation (EMT) . Review revealed a chief complaint of abdominal pain and black stool.

Upon arrival to the ED, a unit of blood was transfusing. Review failed to reveal a stop time for the transfusion. Review of vital signs at 0400 were (T) __, (P) 76, (R) 12, and (BP) 105/74. Further review revealed at 0500 vital signs were (T)___,(P) 75, (R) 15, and (BP) 110/72 with no documented temperature noted. Review revealed a unit of blood was initiated at 0545 with no additional vital signs taken within 30 minutes of initiation of the transfusion per policy. Review revealed the transfusion was completed at 0800 with vital signs of (T)__, (P) 73, (R) 14 and (BP) 108/77 with no documented temperature noted. Vital signs were repeated at 0900, one hour post-transfusion, (T)___, (P) 73, (R) 20 and (BP) 112/80, with no documented temperature noted. Review revealed nursing staff failed to obtain vital signs within 30 minutes of starting transfusion of Unit #2 and within 60 minutes after the transfusion was completed as per policy. Review revealed nursing staff did not follow the blood administration policy.

Telephone interview on 05/30/2018 at 1011 with RN #4 revealed, that nursing staff are trained to obtain at a minimal vital signs of T, P, R and BP within 30 minutes of the start of the blood transfusion. Then document vital signs (T, P, R, and BP) within 10 - 15 minutes once the blood reaches the patient and then at the completion of the transfusion. "During the interview RN #4 was informed the medical record had no documentation of the end time for the unit of blood infusing upon arrival to the ED. RN #4 began the blood transfusion at 0545 at the hospital. "I started the blood and the blood was still infusing when 1st shift came on. I told the day-shift RN (RN #5) the time of the start of infusion." The interview revealed the medical record of blood transfusion failed to reveal the required minimal documentation of baseline T, P, R,and BP at the initiation of the transfusion and at the end time of Unit #2 as required per policy.

Telephone interview on 05/30/2018 at 1057 with RN #5 revealed, "I do know...a full set of vital signs [T, P, R, and BP] are required within 30 minutes of the start time of the blood transfusion, within 10-15 minutes of transfusion (once the blood reaches the patient), at the end of transfusion, and then within 1 hour of the end of (the) transfusion. The significance of checking vital signs at the time of completion of the blood transfusion is to monitor for a reaction. Reaction signs such as increase or decrease in temperature, ... ". Interview revealed nursing failed to follow the blood administration policy.

NC00137923