HospitalInspections.org

Based on record review and interview the facility failed to ensure the patient is notified of grievance investigation resolution, per facility policy in 1 of 3 grievance investigations reviewed (1). This deficiency directly affects Patient #1 and potentially affects all persons who file a complaint.

Findings include:

Per review of policy #GL-6021 titled "Patient Complaints and Grievances" last revised 9/23/16 states "Once the complaint or grievance is resolved, the Patient or Patient's Representative shall be given written notice of the Risk Management Grievance Committee's decision".

Per record review of "Current Summary Grievance Feedback" document # 28708 the facility received the first phone call through the Service Excellence from Patient #1 on 6/13/16 to initiate a grievance alleging physical harm occurred on 6/7/16. "Current Summary Grievance Feedback" form (28708) was initiated at receipt of phone call from Patient #1 alleging physical harm by Staff A. Staff L interviewed on 10/25/16 at 10:30 am confirmed the grievance was then sent to Security Supervisor (Staff M), interviewed on 10/25/16 at 10:40 am who then got email statement of incident from Staff A and viewed video surveillance footage with Service Excellence Staff on 6/24/16. Grievance Feedback document then lists written statement from Staff O, which Staff O confirmed on interview on 10/25/16 at 11:13 am, on 6/24/16. Per documentation Staff L called Patient #1 on 6/28/16 to report "that a full internal review was performed and that (security) supervisor has followed through with this officer" and "I (Staff L) shared that we did not see evidence of (Staff A) having an "outburst" as Patient #1 stated". Staff L documented that Patient #1 stated "he did not apologize to me" and "was not receptive to this as a resolution." At the end of entry from 6/28/16 Staff L stated "Based on this interaction I am sending this back to Legal for follow-up. I have NOT sent a grievance letter to this patient - Legal services please follow up". Staff L sent email to Legal on 6/29/16 requesting "follow up". On 7/11/16 grievance was given to Human Resource Organizational Manager (Staff Z) who documented receipt of complaint, on 7/12/16 reviewed video footage, 7/13/16 interviewed Staff A, 7/15/16 interviewed Staff O and on 7/27/16 interviewed Staff T. Interview with Staff T (Security Guard) on 10/26/16 at 2:10 pm Staff T confirmed incident of Patient #1 in lobby as was in Staff A email statement from 6/23/16.

On 10/26/16 at 2:19 pm Staff A was interviewed and in regards to memory of interaction with Patient #1 was "demanding someone to take her home to carry her into her house" and that after awhile of her "carrying on" someone needed to be the person to say "this has to happen and get her home". He called the taxi and when it arrived helped her into the wheelchair. Staff A denies that he refused to help her to get into the cab. States he pointed out a bar for her to grab. At one point he laced his fingers together with both hands to provide a "step" for her to get into the cab. Staff A states he never touched or moved her legs. This interaction was not on the video provided as there is no camera to capture located in loading area.

Per interview on 10/19/16 at 8:35 AM with Patient #1 on 6/13/16 Patient #1 placed call to Service Excellence department at Gundersen Lutheran Hospital and a formal complaint intake was completed alleging that Security Guard A caused physical harm on 6/7/16. Patient #1 added that the complaint was referred to Staff L (Service Excellence Patient Representative) who on 6/17/16 referred onto Security Supervisor M requesting surveillance video be viewed of 6/7/16 interaction between Security Guard A and Patient #1. Per interview Patient #1 stated she/he did not receive proper information about investigation and follow up.

Per interview on 10/25/16 at 10:00 AM, Staff J stated that Patient #1 was called on 9/9/16 and informed that the investigation was completed and the facility found no evidence to support the allegation. Per interview Staff J stated Patient #1 "was unhappy with this decision and requested it be sent back to legal for re-investigation". Staff J informed Patient #1 "that would not be happening". Staff J stated after the phone call on 9/9/16 was completed Staff J felt that the "issue was resolved" and there was no written notification sent to Patient #1.

On 10/25/16 at 4:02 PM Legal Counsel Y confirmed that investigation into Patient #1 grievance alleging physical harm was considered closed out, and no letter with a description of the investigation and findings was sent to Patient #1.

Based on record review and interview the facility failed to ensure safety of patients during an investigation of alleged patient assault by staff, in 1 of 2 patients (1 )and 1 of 1 staff (A). This deficiency directly affects Patient #1 and potentially affects all patients receiving treatment at the facility.

Findings include:

Per facility policy titled "Caregiver Misconduct, Investigation and Reporting of" #GL 3028, revised 4/11/16, it states under Section II A " All allegations of Caregiver Misconduct, as defined in this policy, shall be immediately reported to Human Resources... II. C. "While investigating allegations of Caregiver Misconduct, appropriate steps will be taken immediately to ensure that patients are protected from subsequent or repeat episodes of Caregiver Misconduct."

Per review of the facility complaint report submitted on 6/13/16, Patient #1 alleges Security Officer A caused pain and damage to Patient #1's body while helping Patient #1 get into a taxi on 6/7/16. Per the complaint record, the incident was not reported to Human Resources for investigation until 7/11/16.

Per interview with Director of Employee and Labor Relations J on 10/31/16 at 2:15 PM, Director J confirmed Security Officer A was not removed from duty upon learning of the incident and during the investigation, and staff usually are but not always, removed from duty during investigations.

Follow up interview on 11/2/16 via email at 10:59 AM, Director J stated they have not done training and are in the process of putting the training together. Director J stated regarding the above facility policy GL3028 and protecting patients "As for removing staff from contact with patients until the investigation is complete in our policy we indicate that while investigating allegations of Caregiver Misconduct, appropriate steps will be taken immediately to ensure that patients are protected from subsequent or repeat episodes of Caregiver Misconduct. We do not state that the employee would be removed from work."

Based on record review and interview the facility failed to individualize patient plans of care and failed to document problems, measurable goals, reassessment and revision to the plan of care. In 2 of 2surgical records reviewed (7 and 8), out of a total of 10 medical records reviewed. This deficiency directly affects Patients 7 and 8 and has the potential to affect all 203 inpatients at this facility.

Findings include:

Facility policy titled "Patient's Plan of Care" #GL-6135 last revised 7/21/16 states "The plan of care identifies individualized care, treatment, and services that will be provided to meet the unique needs of the patient/family" and further under "Management of plan of care" #4 section B in an inpatient setting the registered nurse: "Individualizes the care plan by identifying patient/family needs, goals and/or interventions in the Patient Care Overview template."

Per review of Patient #7s medical record, on 10/24/16 at 3:08 PM Patient #7 was admitted on 10/12/16 with a diagnosis of dislocated elbow. Patient #7's plan of care dated 10/12/16 is not individualized to the diagnosis, has no problems identified, no measurable goals and no interventions.

Per review of Patient #8's medical record on 10/24/16 at 3:35 PM Patient #8 was admitted on 8/12/16 with a diagnosis of a fractured lower leg. Patient #8's plan of care dated 8/12/16 lists standard problem list not individualized to diagnosis with no measurable goals and no interventions.

The above was confirmed in interview on 10/24/16 at 3:35 PM with Staff C and Staff P who acknowledge the plan of care should be individualized with goals and interventions.

Based on record review and interview, the facility failed to ensure staff are documenting alcohol skin based preps are dry before applying drapes to the surgical patient, in 2 of 2 surgical records reviewed (7 and 8) out of a total 10 medical records reviewed. The cumulative effect of this deficiency directly affects Patients 7 and 8, and potentially affects all surgical patients receiving services at the facility.

Findings include:

The facility failed to ensure alcohol based skin prep is documented as dry prior to applying drapes, in 2 of 2 surgical medical record reviews (#7 and 8), out of a total of 10 medical records reviewed. See tag A951.

Based on record review and interview the facility failed to ensure the alcohol based skin prep is documented as dry prior to applying drapes, in 2 of 2 surgical medical record reviews (#7 and 8), out of a total of 10 medical records reviewed. This deficiency directly affects Patients 7 and 8, and potentially affects all surgical patients receiving services at the facility.

Findings include:

Per facility policy titled Asepsis-Surgical Procedure/Sterile Technique, #GL-9141, dated 8/30/16, it states under Surgical Skin Prep in Non-Operative/Procedural Area III.E. "Document the skin prep assessing skin integrity, hair removal process area prepped, solutions used, abnormal reaction to prep, and name of person(s) performing the task." Per interview with Operating Room Manager G on 12/25/16 at 1:22 PM, Manager G confirmed the policy does not state to document the prep is dry prior draping.

Patient #7's medical record review revealed Patient #7 had surgery on 10/12/16 to repair a dislocated elbow. The Intraoperative report dated 10/12/16 has a time out that states an alcohol based skin prep was used to prepare the surgical site. There is no documentation the prep was dry prior to applying drapes. This was confirmed in interview with Operating Room Manager G on 10/24/16 at 3:15 PM, they do not document the dry time.

Patient #8's medical record review revealed Patient #8 had surgery on 8/12/16 to repair a fractured lower leg. The Intraoperative report dated 8/12/16 at 1:16 PM has a time out that states an alcohol based skin prep was used to prepare the surgical site. There is no documentation the prep was dry prior to applying drapes. This was confirmed in interview with Operating Room Manager G on 10/24/16 at 3:15 PM, who added, they do not document the dry time.