HospitalInspections.org

Based on review of the facility's grievance log, patient interview, staff interview, and policy review, the facility failed to follow its written policy for responding to a grievance for 1 of 1 patient grievance received in the last six months (#9). The findings were:

1. Review of the facility's grievance log showed one grievance in the last six months dated 10/23/23 for patient #9. The following concerns were identified:
a. Interview with patient #9 on 1/30/24 at 1:59 PM revealed the patient had filed a written grievance with the facility regarding a care issue at the facility on October 9th, 2023 and as of the date of survey had not been contacted by the facility to address the grievance.
b. Interview with the human resources director on 1/30/24 at 12:30 PM confirmed the facility had received a written grievance from patient #9 and it had been entered into the "Yes System" as required and assigned to the director of nursing (DON) for investigation.
c. Interview with the DON on 1/30/24 at 3 PM revealed she was aware of the grievance from patient #9 and confirmed the patient had not been contacted to seek a resolution.

2. Review of the facility policy "Patient Complaints and Grievances", no date, showed the purpose of the policy was "B. To provide an organized mechanism for identification, analysis, correction, and documentation of complaints or grievances...b. The Director of Quality and Risk will conduct or oversee the investigation of the Grievance..." The procedure described written grievances were "sent to the Director of Quality and Risk. The director will enter the issue in the YES System and coordinate an investigation...A grievance requires a written response to the patient or patient representative within seven business days...If a grievance cannot be resolved with seven business days (the hospital) shall inform the patient or patient's representative that the facility is still working to resolve the grievance and will follow up with a written response within thirty days."

Based on medical record review, patient interview, staff interview, and review of personnel files, the facility failed to meet the nursing needs for 1 of 12 sampled patients (#9). The findings were:

1. Review of the medical record for patient #9 showed an outpatient chest computed tomography (CT) scan with contrast ordered at the facility on 10/9/23. Further review showed an order on the same date to access the patient's "port-a-cath for CT scan." The following concerns were identified:
a. A nursing note in the patient's medical record dated 10/9/23 at 12:29 PM showed the director of nursing (DON) accessed the "implanted port" at approximately 10:40 AM to draw blood and prepare the site for CT contrast. At approximately 11:30 AM the nurse was called to the radiology department for "swelling around the implanted port. Site was swollen, soft, warm, and dry to touch." The procedure was stopped by patient request.
b. Review of the CT report dated 10/9/23 showed the scan was completed without contrast. Further review showed "Moderate amount of extravasated contrast surrounding the port reservoir in the upper right chest."

2. Interview with the patient on 1/30/24 at 2PM revealed the facility did not have anyone trained to access the port but two failed venipuncture attempts made the port the only option for blood work and contrast. The patient stated the DON came to access the port and the patient had concerns about the competency of the nurse from the beginning. The patient described the lack of aseptic technique, lack of appropriate supplies, and the pain and pressure experienced with the needle insertion. After being moved into the CT and the contrast was infused the patient immediately felt "extreme pain" and yelled, "stop this machine!"

3. Interview with radiology tech #1 on 1/29/24 at 10:47 AM revealed the tech remembered patient #9 and remembered the patient wanted the port accessed for the contrast. She verified that accessing a port was out of their scope of practice so nursing was called in to perform the procedure.

4. Interview with the radiology manager on 1/29/24 at 11:22 AM revealed she remembered patient #9. She reported the emergency room nurse tried twice to establish a peripheral IV and was unsuccessful. She verified the facility stocked the needles and appropriate supplies in the radiology department for the nursing staff to access implanted ports.

5. Interview with the DON on 1/30/24 at 3:10 PM confirmed she had accessed the port for patient #9 on 10/9/23 because she "was the only RN on that day." She verified it had been some time since she had performed the procedure (not since her employment with this hospital) and she had not reviewed a skills checklist or video refresher prior to the procedure.

6. Review of the personnel file for the DON showed a contract hire date of 12/20/22. The file showed a current and valid registered nurse license but no evaluation related to performance, training or competency related to nursing skills, including accessing an implanted port.