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Based on record review and interview, the hospital failed to provide the patient with written notice of its grievance decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 10 (Patient #1) patients, in that, the hospital did not send a letter of resolution for Patient #1's 10/29/2014 grievance.

Findings Included

The 10/29/2014 "Event Details" report for Patient #1's post discharge grievance received by Hospital A reflected, "Patient states she arrived at (Hospital B) with a bad bed sore..."

During an interview in an Administrative Office of Hospital A on 03/19/2015 at 1:00 PM, Personnel #4 was asked about Patient #1's complaint. Personnel #4 discussed the 10/29/2014 phone call after Patient #1 was transferred to Hospital B. Personnel #4 stated, "The call was about a bad UTI and bad bedsore. It was handled like a grievance." Personnel #4 was asked for the letter of resolution sent to Patient #1.

During an interview in an Administrative Office on 03/19/2015 at 4:50 PM, Personnel #4 returned and stated, "There was no letter (for Patient #1's grievance call) sent."

The June 2014, last revised "Patient Grievance & Complaint Policy" required, "...formal and informal grievances will be investigated...the patient or patient's representative will receive written communication from the organization within 7 days of the receipt of the grievance...follow up will be provided in the form of a written response within 30 days..."

Based on record review and interview, the hospital failed to ensure a nurse evaluated the nursing care for 1 of 10 (Patient #1) patients, in that, Patient #1 developed a pressure ulcer during the 10/13/2014 admission and the Hospital A's nursing staff did not A) notify Patient #1's physician, B) document the wound on the discharge instructions, and C) notify the receiving hospital, Hospital B, of Patient #1's wound at the time of transfer.

Findings Included

The Hospital A's medical record for Patient #1, admitted on 10/13/2014 reflected there was no wound on admission and on 10/27/2014 at "16:00 (4:00 PM)...Type of Wound Note...Red Purple intact skin with a tear to the right lateral portion of the anal cleft. Site measures 2" x 2.5" overlapping slightly (< than .5") onto each side of the buttocks..."

A) There was no documented indication Hospital A's physician was notified of the wound.

B) There is no documentation on the Hospital A's discharge instructions for Patient #1 that indicated a wound or a need for wound care orders.

C) There is no documented indication Hospital B was notified of Patient #1's wound.
The Hospital B's medical record for Patient #1 admitted on 10/27/2014 reflected, "Initial Nurse Assessment...10/27/14 1800 (6:00 PM) coccyx, stage 3...subcutaneous III..."

During an interview and electronic medical records review in an Administrative office of Hospital A on 03/19/2015, Personnel #7 was asked if the record indicated the physician was notified of the wound. Personnel #7 stated, "No." Personnel #7 was asked if the record indicated whether or not a report was called to Hospital B. Personnel #7 stated, "No." Personnel #7 was asked if the record indicated the patient was given discharge instructions to include the wound or care of the wound. Personnel #7 stated, "No."

The June 2012, last revised "Routine Patient Monitoring" policy for Hospital A required, "Any deviation from normal parameters or physician ordered parameters are to be reported to the physician."

The May 2012, last revised "Discharge Planning" policy for Hospital A required, "includes...specific instructions...physician follow-up...General status information...Patient/Significant Other signature...patient's physical and psychosocial status...A summary of care, treatment and services provided..."

Based on record review and interview, the hospital failed to include a discharge summary with an outcome of hospitalization, a disposition of care, and provisions for follow-up care for 2 of 10 (Patient #1 and #3) patients, in that, A) Patient #1's (Admission 10/13/2014) and B) Patient #3's (Admission 03/11/2015) physician's discharge summary did not include their documented wounds and follow-up care.

Findings Included

A) Patient #1's medical record reflected on 10/27/2014, "16:00 (4:00 PM)...Red Purple intact skin with a tear to the right lateral portion of the anal cleft. Site measures 2" x 2.5" overlapping slightly (< than .5") onto each side of the buttocks..."

There was no documentation on the discharge summary of a wound or a need for wound care orders.

During an interview and electronic medical records review in an Administrative office on 03/19/2015 at 10:30 AM, Personnel #7 was asked if the physician's discharge summary documented the wound. Personnel #7 stated, "No, I don't see it."

B) Patient #3's medical record reflected, "3-12-15 (03/12/2015)...1245 (12:45 PM)...pressure ulcer...Stage II...Left Buttock...2.0 x 2.0 x 0.1..."

There was no documentation on the short stay (discharge summary) report of a wound or a need for wound care orders.

During an interview and electronic medical records review in an Administrative office on 03/19/2015 at 12:43 PM, Personnel #7 was asked if the physician's discharge summary documented the wound. Personnel #7 stated, "No, I don't see it."

The July 2014 Medical Staff "Rules and Regulations" required, "Discharge Summary...shall include primary, secondary and tertiary diagnoses...review of the patient's hospital course, condition on discharge, instructions on discharge and any other pertinent information or data...Short Stays...admissions under forty-eight (48) hours...a Short Stay Form or dictation may be used as history and physical as well as the discharge summary..."