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Based on review of documentation and interviews, the hospital failed to ensure that in its resolution of the grievance, the patient was provided with written notice of its decision that contained the name of the hospital person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process and the date of completion.

Findings included:

1) The Complainant said a written complaint was filed with the Hospital. The Complainant said a phone call was received on 2/17/11 from a Hospital Representative who said the complaint was received and would be looked into. The Complainant said that as of 2/23/11, no further information or action taken regarding the complaint was received.

2) The Patient Representative was interviewed in person on 2/24/11 at 10:10 am. The Patient Representative said the President's Office received the written complaint on 2/16/11 and it was assigned to him/her for investigation on 2/17/11. The Patient Representative said a phone call was made to the Complainant on 2/17/11 to acknowledge receipt of the complaint and to inform the Complainant the issues would be investigated. The Patient Representative said the written complaint was shared with the Housekeeping Supervisor and other relevant staff. The Patient Representative said s/he was "waiting to hear back from folks." No investigational activities, such as interviewing nursing staff or observation of cleanliness of the Inpatient units were taken as of the date of the survey: 2/24/11. The Interim Nurse Manager of the Step Down Unit was not aware of the written complaint and as a result, had not taken any actions to investigate the allegations.

3) Review of the Hospital Policy titled: Patient Complaint Process, section V. Procedure, #3 indicated that when the Patient Care Services Department receives a complaint/grievance, PCS staff will attempt to make contact with the Complainant on the next business day. This communication begin the process of fact gathering and will set out the plan for addressing the complaint/grievance and the estimated time for response. A response will be provided to the Complainant within thirty business days of receipt of the complaint. For grievances, this will include a written response. If the process of resolution takes more than thirty business days, the PCS representative will write the patient a brief letter explaining that the process is continuing and estimating the time to completion.


Although the hospital policy indicated that an immediate call must be made to acknowledge the complaint, and this was completed, there was no information provided to the Complainant in regards to the time frame it would require to conduct the investigation of the allegations. Additionally, at the time of the survey, 1/24/11, the Patient Representative had not conducted any interviews, investigations or observations - resulting in a loss of 8 days in which the investigation could have been proceeding.

Based on review of documentation, interviews and Hospital policy, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient.

Findings included:

1) Review of the policy titled: Acute Care Data Record, section titled Hygiene indicated that nursing staff must document hygiene care provided to the Patient using the codes from the hygiene key which the personal care assistant performs. The section titled oral care indicated the nurse must record the initial completion of oral care.

Review of the Step Down Unit Flow Record dated 1/26/11 at 9 pm indicated Patient #1 was admitted to the Step Down Unit. Review of the column titled Hygiene in which nursing staff document if the patient bathed with or without assistance; complete bath; shower with or without assist; back care; incontinence care and foley care, was blank. Review of subsequent Step Down Unit Flow Records dated 1/26/11; 1/27/11, 1/28/11;1/29/11; 1/30/11 and 1/31/11 indicated the hygiene columns were blank.

Nurse #1, interviewed on 1/28/11 at 9:35 am; Nurse #2, interviewed on 1/28/11 at 8 am; Nurse #3 interviewed on 1/24/11 at 11:15 am and #4, interviewed on 1/28/11 at 8:38 am, all acknowledged they did not document personal care provided to Patient #1 as required per Hospital policy.

2) The Complainant said Patient #1 received a diet that was inadequate for someone in that condition. The Complainant said Patient #1 should have had a bland diet following surgery, but Patient #1 received foods such as chicken pot pie and other items from the cafeteria that Patient #1 could not eat.


Review of the Physician orders dated 1/26/11 on admission indicated for diet: " ADAT (advance diet as tolerated) to regular."

Review of the Step Down Unit Flow sheets from 1/26 through 31/11 indicated the section titled 'Diet' was blank each day, with the exception of 1/29/11 were it was documented Patient #1 received a cardiac diet, which was never ordered, and amounts eaten recorded. On 1/31/11, the day of discharge indicated Patient #1 ate breakfast, 25% independently with the type of diet not recorded.

During interviews with Nurse #1, #2, #3 and #4, all acknowledged that Patient #1's diet type and amount eaten for each meal should have been recorded per hospital policy titled "Acute Care Data Record" which indicated that the nurse must record the type of diet, amount eaten and mode for breakfast, lunch and dinner meals.

Based on review of documentation, interviews and review of six current inpatient medical records for patient on the Step Down Unit, the Hospital failed to ensure that the nursing staff develops and keeps current, a nursing care plan for each patient.

Findings included:

1) Please see Tag A 3095 for details regarding the nursing staff's failure to supervise dietary and personal care assistants provision of daily hygiene care and dietary needs as a component of Patient #1's nursing care plan and Hospital policy.

2) To determine if documentation of personal hygiene and diet information by nursing staff was a current documentation deficiency, 6 medical records were selected of current patients on the Step Down Unit for review. Four of six medical records lacked documentation regarding personal hygiene and diet information on the Step Down Unit Flow Record in the columns titled Hygiene and Diet.

Based on tours of the Step Down Unit, 6 East Medical Unit and 6 West Transplant unit, and Patient interviews, the Hospital failed to ensure that the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.

Findings included:

1) The Complainant was interviewed by telephone on 2/23/11 at 1:40 pm. The Complainant said Patient #1's room was dirty: there were papers, trash and crushed cracker crumbs on the floor. The Complainant said the Housekeeping staff did not clean Patient #1's room every day and Family members had to ask the Housekeeper to clean the room after looking at the cracker crumbs on the floor for several days. The Complainant said it never should have been the responsibility of family members to make sure the room was cleaned on a daily basis.

2) A tour of the Step Down Unit was conducted on 2/24/11 at 9:25 am. During the tour, the main corridors were noted to have paper debris and various sized plastic caps on the floor. Because patients walking the halls wear non-skid slipper socks and several patients were observed walking the halls in the socks - these findings are a slip and fall hazard. When a patient who is walking the hallway steps on a hard plastic top - they may stumble and fall. This is a risk finding. There were also dried dirt/water spots noted on the corridor floor. During the tour, views into several open patient rooms were noted to have dirty floors:
3321 - blue plastic cap on floor along with paper debris.
3328 - paper scraps on the floor.
3332 - plastic caps on floor.
3335 - drinking straw on floor, alcohol wipe pads and bits of paper on the floor.

3) Four patients on the unit were selected to interview and all granted permission for interviews:

Patient #8 in room 3323 - It was noted the floor had dirt spots. Patient #8's blood pressure cuff was hanging from the wall and touching the floor.
Patient #9 in room 3333 - Cracker crumbs were noted on the floor. Paper debris and a gauze square was on the floor.
Patient #10 in room 3330 - The floor was noted to have straws and paper debris on the floor. The urinal was placed on the overbed tray where the food was consumed. Two pillows were placed on the window ledge which could have been placed in the closet where there was space available.

Patient #11 in room 3335 - was on the unit for 8 days. The floor was noted to have paper debris and straws on the floor. Plastic caps were on the floor and Patient #11 was wearing slipper socks. A pillow was noted on the window shelf and not in the closet.

4) An additional tour of the 6 East Medical Unit and 6 West Transplant unit was conducted on 2/28/11 at 10:39 am.

6 East Medical Unit:
Room 613/614 was noted to have water spills on the floor.

Room 606/607 had a rubber glove on the floor near the bathroom door.

The Medication room, which is shared by nursing staff on the East and West unit was observed to have very old and worn 1 inch tiles with dirty grout. The entire room was filled and cluttered with overstock of intravenous bags and medical items. One entire wall was dedicated to wire shelving overstocked with medical items. Under the wire shelving sections, on the floor, against the wall were many medical stock items that had fallen from the shelves: intravenous bags, medical items, empty medication vials, dust and dirt were observed. A tube of calmoseptine was on the floor, tape rolls and gauze packs were on the floor. Each horizontal surface held many items such as: lumbar puncture trays were stacked to the ceiling and nearly touched the old ceiling tiles. The top of the packages were dusty. On top of the medication refrigerator was a sealed inhalant with no patient stamp and open rolls of Tums. The entire medication room was extremely cluttered, disorganized, with a dirty old tile floor and overstocked with medical supplies.

The tub room, which is used by all the patients, also had the same era 1 inch tile that was dirty in appearance with cracked grout.

During the tour, several patient rooms were inspected for cleanliness of the floor:

Room 621/622 - water sports were noted on the floor.
Room 625/626 - paper debris on floor.
Room 627/628 - drinking straw and paper debris on floor.


6 West Transplant Unit:

Tub room - Used by all patients. Observed was the same 1 inch tiles as was noted in the medication room and the tiles observed to be cracked and dirty.
Rooms:
647/648 - paper debris on floor.
651/652 - paper debris on floor.
653/654 - glove on the floor near bathroom entrance. Paper debris, bottle cap and the plastic Venodyne boot used on the patient's leg was lying on the floor.
655/656 - paper debris on floor.

Based on review of documentation, interviews and Hospital policy, the Hospital failed to reassess the Patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan related to the Patient's poor retention of information.

Findings included:

1) The Complainant was interviewed by telephone on 2/23/11 at 1:40 pm. The complainant said that when the Visiting nurse arrived the first day (2/1/11), to assess Patient #1, several drains were clogged and blood had backed up into the Patient's breast area. As a result of the lack of communication and instruction, Patient #1's breast area was very sore and swollen. The Visiting Nurse instructed the Patient's family how to milk the drains. The Complainant said Patient #1's pain caused from this lack of instruction was completely unnecessary and could have been avoided with proper instruction from the nurse who discharged Patient 1 from the Hospital.

2) The Visiting Nurse Association [VNA] Supervisor was interviewed by telephone on 1/23/11 at 2 pm. The VNA Supervisor said there was an admission entry by the Visiting nurse on 2/1/11 which indicated there were 4 out of 6 drains clogged with clots. The VNA Supervisor said the Patient's Family was instructed on how to properly milk the drains and keep them clean. The VNA Supervisor said the Visiting Nurse was able to get the drains to work properly again.

3) The Care Coordinator [CC] who sets up home care and VNA Services was interviewed in person on 2/24/11 at 10:10 am. The CC said s/he met with Patient #1 on 1/28/11 at 9:41 am and documented the chart was reviewed and met with Patient #1 & Spouse. Referral made to VNA. The CC said she completed the discussion and went to the desk to document. Within minutes, the nurse assigned to Patient #1 asked the CC if she had explained discharge plans to Patient #1. The CC said she was surprised because s/he had literally just left Patient #1's room. The CC said she reentered Patient #1's room and asked if Patient #1 remembered speaking with her and Patient #1 replied she did not. The CC said she went over the information again. The CC said Patient #1 had issues with information retention and recall.

4) Review of the Inpatient/Family Education Record dated 1/29/11 indicated the discharge plan was reviewed with Patient #1. Documentation on 1/29/11 indicated the procedure for milking the JP drains was covered with Patient #1.

5) Nurse #4 who discharged Patient #1 on 1/31/11 was interviewed on 2/28/11 at 8:38 am. Nurse #4 said she spent a great deal of time reviewing JP drain care with Patient #1 and observed Patient #1 perform the procedure. Nurse #4 said s/he documented that all 6 drains were milked and the amount obtained prior to discharge on the 1/31/11 Step Down Unit Flow Record.

6) Review of the medical record indicated Patient #1 was provided with written discharge instructions that included a section on JP drains care and maintenance. Nurse #4 said s/he also provided Patient #1 with a paper grid that mapped out the 6 drains along individual columns so Patient #1 could record times the JP drains were milked and the amounts of fluid obtained. Nurse #4 said s/he sat with Patient #1 for 45 minutes going over the care of the JP drains.

7) Review of the Hospital policy titled: Guidelines for use of Patient Discharge Care Forms, section on nursing responsibilities indicated the nurse who discharges the patient will review the information contained on the forms. The nurse will obtain the Patient's signature after the information on the completed forms are reviewed with the patient. The nurse also signs the forms. Review of the discharge instruction form indicated Nurse #4 and Patient #1 signed the document on 1/31/11. By signing the document, Patient #1 agreed that: "Patient and/or caregiver has received discharge instruction and demonstrated clear understanding of care plan for discharge and medication instructions."

8) According to documentation and interview, both the Care Coordinator and Nurse #4 provided discharge education, instruction regarding how to milk the JP drains and observed Patient #1 perform the task. The CC set up the home based VNA services.

9) Documentation and Interview with Nurses # 1-#4 and the Care Coordinator indicated Patient #1 had issues regarding retention of information and recall.

10) Patient #1 perceived her discharge instruction as inadequate despite having signed the discharge instruction form attestation of receipt and comprehension.