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Based on interview and record review, the hospital failed to ensure the complaint process was followed to complete an investigation and notify the patient of the result of the investigation for 4 (Patient #13, #14, #15, #16) of 7 complaints reviewed.

The findings included:

1. A Patient Guide was given to each patient upon admission to the hospital. In the section titled Rights & Responsibilities (on page 25) included the patient has a right to be informed of the resolution process for your concerns.

According to policy and procedure ORG-G.002 Grievances and Complaints: Patient (approved 4/26/16), the hospital differentiates 2 levels of concerns. The first level identified as complaints were identified as patient concerns which could be resolved immediately. The next level was identified as grievances. The policy and procedure said complaints or concerns may be related to patient care of quality or medical services. The department director was to conduct an investigation and attempt to resolve the issue. If the director was unable to resolve the issue, then the event is entered into the computer as a grievance. The policy continues to describe an investigation, and gave timeframes for resolution and the need to notify the patient of the results of the investigation in writing.

The hospital has a single form used for documentation of either complaints or grievances.

On 12/19/16 at 1:11 p.m., the Patient Advocate described the procedure for the complaint/grievance form. He reported he saw most every patient on a daily basis and would ask about concerns. This information was then placed into the form and he would solve it, or transfer to the department head for investigation, but he is unaware whether an actual investigation was conducted. He does identify in the document whether it was a grievance or a complaint investigation. All documents given for review were identified as complaints.
At 3:34 p.m., the Patient Advocate said he determined the categories of complaints and he sometimes notified the Risk Manager. He said if he felt he had completed the investigation, he did not refer the document to the Risk Manager.

On 12/19/16, the Risk Manager reported she receives the form when it is first started, but if it was identified as a complaint she does not see the form or investigation again. She does not track or trend the ones identified as complaints. She said the Patient Advocate was responsible for giving the complaint to hospital staff for investigation. She said the staff were responsible for investigating the issue, but agreed the form does not show what the investigation was, what was found, and the resolution to the patient. She said it was a problem with the computer system. The Risk Manager said she has investigated only 2 grievances since the start of 2016.

On 12/19/16, 7 compliant documents were reviewed. Two of the documents were complements, and the other 5 were complaints.

2. Patient #13 had a complaint regarding a lack of response about pain medication, having to wait for the medication, dirty linens in a chair for the entire day, missed dosages of antibiotics (a whole day according to the patient), and a very rude ultrasound technician who hurt the patient during the procedure. The Patient Advocate took the report and apologized to the patient.

The complaint document was referred to the department heads of Medical/Surgical and Radiology and to the Risk Manager. The Patient Advocate verbally acknowledged the complaint to the patient. There was no documentation of the results of the investigation or outcome. There was a counseling document for the ultrasound tech, but it was not dated or signed by either the ultrasound tech or the Department Head of Radiology.
On 12/20/16, review of the medication administration record revealed the patient missed 2 does of Flagyl (an antibiotic ordered every 6 hours) for the 4:00 p.m. doses on both 10/7/16 and 10/8/16. There was no explanation in the record for the missed doses.

On 12/20/16 at 2:24 p.m., the Director agreed there was no documentation regarding the missed doses. Based on the documentation, it was not possible to determine if there was an excessive wait for pain medication.

On 12/19/16 at 4 p.m., the Director of Medical/Surgical said she gets grievance forms from risk management and investigates. She said she would not necessarily write the investigation results on the grievance form or anywhere else. If she did official counseling, she would write something down.

On 12/22/16 at 11:12 a.m., the Director confirmed she had not investigated Patient #13's record for the identified issues and had not done an investigation.

3. Patient #14 had issues with pain management on 9/21/16 according to the complaint form. There was no documentation of an investigation.

4. According to the complaint form dated 9/20/16, Patient #15 called to complain he had not seen his doctor all day and had wanted the family present during the physician visit. The supervisor was notified, called and left a message for the doctor. There was no documentation if the physician ever saw the patient and whether the patient was satisfied with the resolution. There was an order by the physician written that day. There was no documentation anyone spoke to the patient about the resolution. The complaint was closed on 10/24/16.

5. On 8/25/16, Patient #16 complained the overhead paging of staff was making it very difficult to rest. The patient reported just falling asleep and being jarred awake by the page. The Patient Advocate apologized and explained it was impossible not to page staff, but he would speak with the unit and request it be kept to absolute minimum and to speak with staff without paging first. The documentation noted it would be discussed at staff meeting. There was no evidence if this response was acceptable to the patient, and no follow up with the patient as long as they were hospitalized to determine if this intervention was effective for patient comfort (the hospital eventually discontinued paging and changed to a phone for each staff).

Patient #18 on 8/22/16 was upset about the length of time it took to answer the call light. He said it didn't happen all of the time, but he was videotaping the clock to show the time. The patient was asked to stop videotaping, and if he had to wait more than 30 minutes he should call the Patient Advocate to intercede for the patient. There was no follow-up documentation to confirm the patient was satisfied with this response and whether the intervention was working in resolving the issue.

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Based on interview and record review, the hospital's Board of Directors was neither involved in patient complaints/grievances nor had they assigned an alternate committee for this.

The findings included:

1. During an interview on 12/20/16 at 2:53 p.m., the Risk Manager indicated the governing body was not informed regarding any of the grievances or complaints the hospital had received. She said she does not know of any committee was assigned to this task. She said she knows it was not assigned in writing to any committee.

On 12/22/16 at 4:30 p.m., the Administrator admitted he was unaware of the need for this reporting system.

2. According to policy and procedure ORG-G.002 Grievances and Complaints: Patient (approved 4/26/16), the Board of Trustees was to receive risk management quarterly reports including all grievances and complaints.

On 12/19/16, at 2:59 p.m., the Risk Manager reported she does not receive complaints back from the administrative staff after investigation. She does not see the results. She did not track and trend the complaints. The complaints did not get reported to the Board of Trustees (the governing body).

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Based on record review and interview, the facility failed to have an assigned family member or surrogate appointed for making medical decisions for 1 (Patient #2) of 3 patients sampled.

The findings included:

1. A Patient Guide was given to each patient upon admission to the hospital. The section titled Rights & Responsibilities (on page 24) included the patient has a right to "have a surrogate decision-maker participate in care, treatment and services decisions when you are unable to make your own decisions."

2. Clinical record review revealed Patient #2 was admitted on 10/10/16. When the patient was admitted, the patient was unresponsive and could not make his wishes known. The initial paperwork was signed by a person whose relationship to the patient was not identified. The emergency room record said the patient was admitted with the spouse and another relative.
On 12/22/16 at 3:00 p.m., from information provided by the Case Manager, the person identified as the spouse was actually an ex-spouse. Patient #2 had 9 children who were all involved in the care. The patient had 14 different procedures performed while in the hospital. In each case, a different relative signed the consent for the patient. The hospital made no determination of a patient representative or surrogate.

3. The hospital face sheet identified the patient's daughter and eldest son as the people to contact.

On 12/22/16 at 3:00 p.m., the Case Manager agreed there were issues with Patient #2 as to who was responsible for making decisions for the patient. The person identified in the ER as the patient's spouse who signed the emergency room (ER) paperwork was an ex-wife.
The Case Manager explained since there were multiple people making decisions, a meeting was held with the family on 11/4/16 (more than 3 weeks after admission) to discuss code status and the treatment plan going forward. One of the reasons for the meeting was to determine who would be the responsible person and who the hospital should deal with. The family decided would be the decision maker. The hospital never established surrogacy documentation for the son.
The Case Manager acknowledged this was identified as a hospital-wide concern after the meeting. She agreed the system has not been completely put into place to keep this from happening again.

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Based on record review and interview, the hospital failed to ensure 1 (Patient #2) of 3 sampled patients was safely transferred from bed to bed resulting in damage to the breathing tube and subsequent need to change the tube putting the patient at risk.

The findings included:

1. A review of the policy and procedure Transport of Patients within the Facility (revised 10/2013) revealed the following: "10. Any patient on a ventilator or in severe respiratory distress will be transported with an RN [registered nurse] or Physician and a Respiratory Care Practitioner (RCP) in attendance to assist with the airway/breathing and ventilator needs."

2. On 12/19/16, 3 nurses were interviewed, RN Staff A at 4:30 p.m., RN Staff B at 1:59 p.m., and RN Staff C on 12/19/16 at 1:23 p.m. The nurses said before they would move any patient they would ensure respiratory therapy was present if the patient was on a ventilator, even for a move from one bed to another.

3. A review of records revealed Patient #2 was admitted 10/10/16 with multiple medical conditions including respiratory failure. He was intubated (attached to a ventilator to breathe for the patient).
Respiratory therapy note dated 11/3/16 at 9:04 a.m. revealed the patient had a change overnight in cardiac status. "Since changing beds on the night shift last night", the patient's ventilator pressures had dropped. It was noted the breathing tube had a possible leak The respiratory therapist (RT) tried, but was unable to correct. A therapy note at 11:08 a.m. indicated this continued to be an issue for the patient. As a result, the doctor came in to perform a bronchoscopy to insert a new breathing tube.

On 12/21/16 at 10:00 a.m., RT Staff D said as far as he knew no RT was present for the move from one bed to the other (from a standard bed to a "big boy" bed). There was no documentation about any of this in the nursing notes.
On 12/21/16 at 11:00 a.m., RT Staff E, who was on duty at the time of the transfer, confirmed she was not in the room when the patient was transferred.

4. On 12/19/16 at 3:58 p.m., the Director of Medical/Surgical (who was also director of the intensive care unit) confirmed a patient who was on a ventilator and had a breathing tube must be moved/transferred with a RCP present.

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Based on interview and review of the organizational chart, the hospital failed to ensure there was a medical director for the respiratory department.

The findings included:

A review of the organization chart for the hospital revealed the respiratory department was part of the cardiopulmonary section. The person named as responsible for this department was labeled as the Department Manager Staff F.

On 12/22/16 at 4:00 p.m., the Risk Manager said there was no physician responsible for the respiratory department since the sleep study unit was discontinued. She said it had been awhile (at least several months), but she could not confirm the exact length of time.
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Based on record review and interview, the hospital respiratory staff failed to insure 1 (Patient #2) of 3 patients was transported in such a manner to protect the respiratory tube from displacement, resulting in damage to the breathing tube and subsequent need to change the tube putting the patient at risk

The findings included:

1. A review of the policy and procedure Transport of Patients within the Facility (revised 10/2013) revealed the following: "10. Any patient on a ventilator or in severe respiratory distress will be transported with an RN [registered nurse] or Physician and a Respiratory Care Practitioner (RCP) in attendance to assist with the airway/breathing and ventilator needs."

2. On 12/19/16, 3 nurses (who worked in ICU when it was open) were interviewed, RN Staff A at 4:30 p.m., RN Staff B at 1:59 p.m., and RN Staff C on 12/19/16 at 1:23 p.m. The nurses said before they would move any patient they would ensure respiratory therapy was present if the patient was on a ventilator, even for a move from one bed to another.

3. On 12/19/16 at 3:58 p.m., the Director of Medical/Surgical (who was also director of the intensive care unit) confirmed a patient who was on a ventilator and had a breathing tube must be moved/transferred with a RCP present.

4. A review of records revealed Patient #2 was admitted 10/10/16 with multiple medical conditions including respiratory failure. He was intubated (attached to a ventilator to breathe for the patient).
Respiratory therapy note dated 11/3/16 at 9:04 a.m. revealed the patient had a change overnight in cardiac status. "Since changing beds on the night shift last night", the patient's ventilator pressures had dropped. It was noted the breathing tube had a possible leak The respiratory therapist (RT) tried, but was unable to correct. A therapy note at 11:08 a.m. indicated this continued to be an issue for the patient. As a result, the doctor came in to perform a bronchoscopy to insert a new breathing tube.

On 12/21/16 at 10:00 a.m., RT Staff D said as far as he knew no RT was present for the move from one bed to the other (from a standard bed to a "big boy" bed). There was no documentation about any of this in the nursing notes.

5. On 12/21/16 at 10:00 a.m., the Manager of Respiratory confirmed she was aware of the incident and said respiratory therapy was not bedside during the transfer from bed to bed.

On 12/21/16 at 11:00 a.m., RT Staff E, who was on duty at the time of the transfer, confirmed she was not in the room when the patient was transferred.