HospitalInspections.org

Based on record review, policy review, and interview, the facility failed to ensure that complaints, which met the definition of a grievance, were appropriately identified as grievances and followed the grievance process for four (#1, #24, #25 and #26) of six complaint records reviewed, and failed to follow the internal policy for timelines for written resolution response to patients or their representative who filed a grievance for two (#22 and #29) of four grievance records reviewed The facility census was 388.

Findings included:

1. Record review of the facility's policy titled "Response to Patient Complaints" revised on 12/13/10, showed the following direction:
-A grievance is a perceived violation of patient's rights;
-A grievance may arise when initial attempts at the department level to resolve a complaint were deemed unsatisfactory by the patient, family, or related party;
-A grievance may include situations where the patient or the patient's representative notify the hospital whether verbally or in writing about concerns related to care or services;
-Complaints, if submitted in writing, will be identified as a grievance;
-Verbal complaints expressed after the patient discharge will be assessed by the department manager or Guest Relations staff, and may be determined to be a grievance;
-A patient representative included family and friends who are believed to have knowledge of the patient's wishes and values;
-Any unresolved verbal/written concern will be considered a grievance and will require an investigation and a written response within seven days;
-A written progress report will be provided to the complainant every ten days until the final resolution of the grievance and should include steps taken to investigate the dispute, the results of the investigation to date, and the name of a hospital contact in case additional information is needed;
-All grievances that have not been resolved within 30 days will be reviewed by the Patient Safely leadership Team.

2. During an interview on 06/27/12 at approximately 10:00 AM, Staff EE, Director of Patient and Family Centered Care stated that the complaint policy was written "vaguely" so that the facility would be able to escalate a complaint to a grievance without being bound by a policy. Staff EE stated that she recognized that the verbiage used in the policy also allowed for a grievance to be managed incorrectly as a complaint.

3. Review on 06/27/12 of a "complaint" filed by Patient #25's family member on 06/11/12, showed that the patient informed a "male nurse" that she was placed on a bed pan incorrectly, but the "male nurse" didn't change the position of the bed pan, which caused her bed sheets and gown to become wet (with urine). The "male nurse" was notified by the patient that her sheets and gown were wet, but "she was ignored". "The next morning" the patient informed another nurse what happened and the "male nurse" was sent back into the patient's room to change the patient's wet sheets and gown. Further review of the "complaint" showed that the 5 West Surgery Department was to review and determine resolution, which was "still in progress". The record did not indicate that an investigation was completed or that a written response was made to the patient or the patient's representative.

During an interview on 06/26/12 at 4:35 PM, Staff EE stated that the complaint filed by Patient #25's family member was not considered a grievance and did not receive a written response because:
-It was received by phone and not in written form;
-The family member making the complaint did not request feedback;
-Responding to the patient's family complaint would be a violation of Health Insurance Portability and Accountability Act (HIPAA - protection of patient health records and medical information);
-It was not thought of as possible neglect of the patient or a violation of her patient rights.

4. Review on 06/27/12 of a "complaint" filed by Patient #24's family member on 03/09/12 showed that the family member did not believe the patient was safely discharged from the facility's Psychiatric Unit and that the patient could not be found (after he was discharged) after searching for him. The complaint also stated that another family member, who identified themselves as the patient's Durable Power of Attorney (DPOA - a person designated by the patient, to act on his/her behalf in the event the individual becomes disabled or incapacitated) called the facility earlier in the day and was informed by the facility that Patient #24 had been discharged. The DPOA was upset and alarmed that the patient was discharged without the DPOA's involvement. The "complaint" showed an extensive investigation was completed by the facility but did not indicate that a written response was made to the patient or the patient's representative.

During an interview on 06/27/12 at approximately 10:00 AM, Staff EE and Staff N, Coordinator of Quality Improvement stated that the complaint made by Patient #24's family members was not managed as a grievance and that a written response was not sent to the patient or family member. Staff N stated that it was a violation of HIPAA to provide information to the patient's family member in response to the complaint and questioned whether the patient's family member had the right to file a complaint, since she was unsure if the family member was the patient's DPOA and because Patient #24 was a psychiatric patient.

5. Review on 06/27/12 of a "complaint" filed by Patient #26's family member on 01/06/12, which was submitted in writing, showed that the family member and Patient #26 were left alone in a room and without communication from 7:30 (AM or PM not documented) until "12:30 or 1 AM" while Patient #26 was waiting to be seen by a Mental Health Physician. The facility's documentation of the "complaint" showed that the patient's record was reviewed, but did not indicate that a written response was made to the patient or the patient's representative.

During an interview on 06/26/12 at 4:35 PM, Staff EE stated that she didn't realize that Patient #26's family member had submitted a written complaint until "today", that because the complaint was submitted in written form that it should have been managed as a grievance, and that a written response was not sent to the patient or patient representative.

6. Record review on 06/27/12, of a "complaint" (not identified as a grievance by the facility) filed by Patient #1's family member on 05/04/12, showed that the patient stated her home medications were left behind when she was discharged from the hospital. The "complaint" indicated that an investigation into the missing medications was conducted and the patient was notified on 05/07/12 that the medications were given to her family member while in the Emergency Department (ED). Further documentation on the "complaint" showed that the patient's family member contacted the facility on 05/09/12, by phone, and stated that she received the patient's medication in the ED, but the medications were left behind again when the patient was admitted. Patient #1's family member added that a nurse (specifically named) informed the family member that she had taken the medication up to the patient's hospital unit, but the family member could not locate the medications in the patient's room (indicating that the concern remained unresolved). On 05/15/12, documentation on the "complaint" record indicated "Sending pt. (patient) another letter. We have not been able to locate meds (medication)", but did not indicate that the written response included the steps taken to investigate the unresolved concern and a copy of the written response was not provided by the facility.

7. Record review on 06/27/12, of a grievance filed by Patient #22 on 02/23/12, showed that the patient complained that his physician "cut off all communication with me". The facility responded to the patient on 02/23/12 by email, and informed the patient that a review would be conducted and that the facility would "respond to you regarding the outcome of this review by Thursday, March 8, 2012" (14 days after the initial response). A response letter was sent to the patient regarding the grievance outcome on 03/08/12 (14 days after the initial response).

During an interview on 06/27/12 at approximately 10:00 AM, Staff EE and Staff N stated that the complaint and grievance policy stated that all grievances are required to receive a written follow-up within seven days and if the grievance is not resolved at that time, a letter is sent every ten days until the grievance is resolved. Staff EE stated that the she didn't have an answer as to why the initial letters sent to patients indicated the expected final resolution would be sent to the patient with a date greater than 10 calendar days from the initial letter, or why the final resolution letters were sent after 10 days.

8. Record review on 06/27/12, of a grievance filed by Patient #29 on 06/01/12, showed that the patient complained she was still "waiting for home health to be arranged after being discharged 05/28/12". The facility responded to the patient by letter on 06/06/12, and informed the patient that a review would be conducted and that the facility would respond to the patient regarding the outcome of the review on 06/20(no year) (14 days after the initial response). The facility sent a response letter to the patient on 06/18/12 (12 days after the initial response).

During an interview on 06/27/12 at approximately 10:00 AM, Staff EE stated that staff should have responded to Patient #29 with a final resolution within 10 days after the initial letter was sent.

Based on observation, interview, and policy review, the facility failed to keep medication storage areas locked and accessible only to authorized hospital staff members in one of one Interventional Pain Management outpatient clinic. This has the potential to affect all patients undergoing Interventional Pain Management by placing medication stock at risk for tamper or change by unauthorized staff. The facility census was 388. The clinic sees on average 220 patients a month.

Findings included:

1. Record review of the facility's policy titled "Medication Management", provided by the Manager of Regulatory Affairs, Staff D on 06/28/12, showed the following direction:
- Access to medication storage areas is limited to authorized hospital staff members. Licensed Staff who are authorized to administer medication in the state of Missouri will be given access to medication. To insure the security of the medication storage areas, user identification and authentication procedures will be in effect.
- JCAHO (Joint Commission Accreditation of Hospitals Organization), Missouri State (Department of Health) regulations pertaining to Pharmaceutical Services in hospitals, the Mo State BNDD (Missouri State Board of Narcotics and Dangerous Drugs), and the Federal DEA (Drug Enforcement Agency) require that medication storage areas with or without controlled substances be locked and accessible only to authorized personnel.
- All medications including those stored in the medication carts, nurse serve drawers, medication refrigerators/freezers (where present); Pyxis medication stations and outpatient supplies are kept locked and secured according to UMHC (University of Missouri Health Care) policies.

2. Observation on 06/27/12 at 4:05 PM showed an unlocked cabinet in the patient procedure room containing the following medication:
- Omnipaque injection (contains iodine to increase visualization during X-ray (to study various structures within the body)
- Sodium Chloride - salt water to use in medication administration
- Dexamethasone injection - reduce swelling, heat, pain
- Kenalog injection - reduce swelling, heat, pain
- Bupivacaine injection - relieve pain
- Lidocaine HCL injection - relieve pain
- Sodium Bicarbonate injection - lower blood acidity
- Botox - used to treat neck pain
- Epi pen - treat breathing problems
- Solu Medrol injection - reduce swelling, heat, pain
- Diphenhydramine HCL injection - relieves itching, allergic reactions

3. During an interview on 06/27/12 4:10 PM, Staff PP, Licensed Practical Nurse, stated that front staff (nonclinical) let cleaning personnel into the room, no one is in the room when cleaning personnel clean the room and the cabinet with the medications does not have a locking device.

4. During an interview on 06/27/12 at 4:15 PM Staff QQ, Executive Director of Ambulatory Care, stated that nonclinical staff and cleaning personnel should not have access to drug rooms and that only clinical staff should have access to rooms containing drug therapy.

Based on interview and record review, the facility failed to notify The Centers for Medicare and Medicaid Services (CMS) by telephone the death in restraints of one (#56) of one discharged patient and 57 of 57 patient deaths that occurred in soft restraints from 01/01/12 to to 06/21/12. The facility census was 388.

Findings included:

1. Record review of the facility's policy titled, "Reporting of Patient Death When in Restraints" revised 03/23/10, showed the policy did not give direction for staff to notify CMS per telephone of deaths that occurred while in soft restraints.

2. Review of discharged Patient #56's Hospital Restraint/Seclusion Death Report Worksheet dated 03/02/12, showed the following information:
-Date of Death: 03/01/12;
-Date reported to CMS Regional Office: March 2, 2012; and
-Staff documented the date and time the death was reported to CMS. The record did not document staff notified CMS by telephone.

During an interview on 06/28/12 at 9:55 AM, Staff D, Manager of Regulatory Affairs, stated that CMS was notified of the Patient #56's death while in soft restraints by fax on 03/02/12. Staff D stated all events of patient deaths while in soft restraints are reported to CMS by fax.

3. Review of the facility's "Death in Restraint Log 2012" showed 57 patient deaths occurred while patients were in soft restraints from 01/01/12 to 06/21/12 for a total of 58 (including Patient #56).

4. During an interview on 06/28/12 at 10:40 AM, Staff D stated that the office received direction from CMS to stop calling them with reports of patient deaths while in soft restraints and just fax the information to the office.

5. Review of the email document presented by Staff D dated 04/16/09, showed the following direction from CMS:
-Subject: FW: July 2008 Revised Worksheet to Report Hospital Restraint/Seclusion Deaths
"If you email the report to the web address at the bottom of this message, attach the completed document, and we will respond when we have reviewed and' received' it.

You need not telephone in addition to either emailing or faxing us the form, but may certainly do so if you wish.

While regulation requires hospital staff to telephone the CMS Regional Office and staff in this office will always accept information provided in this manner, staff in this office believe that the intent of the regulation is that hospital staff report and, therefore, will also accept reports received either through a secured, dedicated fax number or email address. In short, hospital staff may report the death and the information required through any method they choose. These methods include the following:
-Telephone
-Dedicated, secured fax number
-Dedicated, secured email address
If a report is either faxed or emailed, we do not expect hospital staff also to telephone us, although they may do so if they wish."