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Based on family interview, staff interviews, and facility policy review, the facility failed to follow a timely grievance process.

Findings include:

An interview with Patient 1's spouse on the afternoon of 8/4/14 revealed she hadn't yet heard from the facility regarding the complaint she filed on 5/15/14. Patient 1's spouse was unhappy with the treatment the patient received after receiving bilateral knee replacement surgery on 5/15/14. Following the elective knee surgery, Patient 1 experienced extreme pain. Several hours following surgery the facility staff realized he wasn't connected to the Intravenous (IV) line which delivered the pain medication, Morphine. The spouse of Patient 1 stated it was okay for the facility to know who filed the complaint.

Upon entrance to the facility on 8/5/14, the facility reported they were unaware that Patient 1's spouse submitted a written complaint. The Patient Relations department was the unit which received grievances and complaints. The Patient Relations Representive (Representative) reported they hadn't received a written complaint. Upon further investigation, the Representative found the written complaint and reported it had been misfiled.

Interview of the Representative and the Manager for Quality and Patient Safety (Manager) on the morning of 8/6/14 at approximately 10:00 A.M. revealed the Representative's recollection of Patient 1 and his spouse. She recalled seeing the patient and spouse on 5/15/14 to assist with resolution of their complaint. The Representative stated the facility's focus was to make things right while the patient was still in their facility. The Representative stated that since the complaint was misfiled, the patient/spouse were not provided with a written or verbal response to their complaint. The Manager and Representative stated that Facility policy was to provide complainants with a written response. In addition, the Manager and Representative both reported that on the complaint form, Patient 1's spouse checked off that she wanted written notification.

A review of the facility policy titled, "Patient Complaint and Grievance Process", revised 11/8/13, noted: "4.2.3.2...The resolution to most grievances is reached within 7 days as practicable, and a written response is generated to the patient or patient's representative." The policy further indicated, "If the grievance will not be resolved within 7 days or if the investigation will not be completed within 7 days, Patient Relations will inform the patient or patient's representative that the Patient Relations Department is still working to resolve the grievance and the anticipated timeframe in which the patient or patient representative can expect a written response."

Based on family and staff interviews and facility policy review, the facility failed to respond to a complainant within a timely manner.

Findings include:

Patient 1 was admitted to the facility on 5/15/14 for bilateral knee replacement surgery. He experienced extreme pain after surgery because a Licensed Nurse didn't connect his Intravenous line for him to receive pain medications. Patient 1's spouse filed a complaint on 5/15/14 requesting a written response from the facility. Interview of Patient 1's spouse on 8/4/14 revealed she still hadn't received a response from the facility.

Interview of the Representative and Manager on the morning of 8/6/14 revealed the complaint was received and misfiled. Since it was not appropriately filed, the facility did not provide a written reponse to Patient 1/spouse.

A review of the Facility policy titled, "Patient Complaint and Grievance Process," indicated that the facility would provide the complainant a written response within 7 days. Since the complaint was not investigated upon the SAs on 8/5/14, the complainant had not been provided a written response.

Based on review of grievances, staff interviews, and facility policy review, the facility failed to provide the necessary notification to resolve a grievance filed by Patient 1.

Findings include:

A complaint was filed by Patient 1's spouse regarding care received at the facility on 5/15/14. A review of resolved/investigated grievances revealed the facility provided written notification of grievance status/resolution.

Interview of the Manager and Representative on the morning of 8/6/14 revealed that written responses were provided for all complaints. The Representative further indicated that because of the misfiled complaint, Patient 1/spouse had not been given written notification of the outcome of their complaint as of 8/5/14 when the SA entered the facility to conduct the investigation.

A review of facility policy titled, "Patient Complaint and Grievance Process," revised 11/8/13, noted under 4.2.3.2..."A written explanation of the hospital's determination regarding the grievance is communicated to the patient or the patient's representative in a language and manner that is understandable to the patient or patient's representative. In all cases, Patient Relations provides a written response to each patient's grievance that includes the following: Name of hospital contact person; Steps taken to investigate the grievance; Results of the grievance process; and Date of completion (usually the date of the letter)."

Based on interviews, record review and facility policy review, the facility failed to properly administer pain medication to a patient after surgery.

Findings include:

A record review revealed that Patient 1 had bilateral knee replacement surgery on 5/15/14. The patient was sent to the Recovery Room after surgery and was experiencing extreme pain in both knees. The Patient 1 reported his pain level at 10 out of 10 on a scale of 1-10 (1=little to no pain, 10=extreme pain). The physician ordered a Patient Controlled Analgesic (PCA) system which allowed the patient the option to press a button for pain medication to be released into his intravenous (IV) line whenever he needed more pain relief. The PCA was started in the Recovery Room at approximately 1:30 P.M. The Licensed Nurse, LN #1, went on a lunch break and LN #2 covered Patient 1 for her. The PCA system required a connection to an IV line, which was on Patient 1's hand/wrist. The narcotic used in the PCA for Patient 1 was Morphine.

Review of the PCA flow sheet and Medication Administration Record (MAR) found Patient 1 was experiencing extreme pain immediately following surgery. The following pain ratings were noted on the PCA flow sheet dated 5/15/14: 1:30 P.M. 10/10; 3:00 P.M. 8/10; 3:35 P.M. 10/10; 7:30 P.M. 8/10; 8:30 P.M. 7/10.

At 12:48 P.M., when Patient 1 arrived in the Recovery Room, the LN #1 provided him with Fentanyl via IV push. The physician's orders noted Fentanyl Citrate (PF) Injection 12/5-25 mcg every 5 minutes as needed for pain, not to exceed 200 mcg. Documentation in the MAR noted he received Fentanyl 25 mcg at 12:30 P.M.; 25 mcg at 12:35 P.M.; 25 mcg at 12:40 P.M.; 25 mcg at 12:45 P.M.; 25 mcg at 12:55 P.M.; and 25 mcg at 1:00 P.M. Patient 1 had orders for Dilaudid (PF) Injection 0.2 mg every 10 minutes as needed for pain, for a total of 1 mg. Patient 1 received Dilaudid via IV push: 0.2 mg at 1:00 P.M.; 0.2 mg at 1:15 P.M.; 0.2 mg at 1:27 P.M.; 0.2 mg at 1:35 P.M.; and 0.2 mg at 1:40 P.M. Patient 1 also had orders Oxycodone Immediate Release 5-10 mg tab orally every 4 hours as needed for pain. The Patient 1 received Oxycodone immediate release tablet 5 mg at 1:56 P.M. Despite the administration of these pain medications in addition to the PCA dosing, the Patient 1 continued to experience extreme pain.

Record review for Patient 1 revealed his lack of pain relief. The LN 1 noted the patient was started on the Morphine PCA at 1:30 P.M. The continuous rate of Morphine via PCA was 1 mg per hour and bolus 1 mg every 6 minutes. At 2:30 P.M. the LN 1 notified the patient's physician because of the patient's continued pain. The physician ordered Ofirmev which the LN 1 administered. The patient was noted to have some periods of sleep. At 3:30 P.M., the Morphine PCA continuous dosage was increased to 2 mg per hour. The patient was resting if undisturbed but stated his pain level was 6-7/10.

The Patient 1 was transferred to an acute hospital bed, as was planned for post operative recovery, at approximately 3:35 P.M. on 5/15/14. Report was given by LN 1 to LN 3, who was assisting to settle Patient 1 for his primary nurse. Interview of LN 3 on the afternoon of 8/6/14 at approximately 2:30 P.M. revealed that she was assisting the primary nurse with transferring the patient onto the floor. The LN 3 stated she conducted an assessment of Patient 1 and when she pulled off his blankets, she discovered the PCA was not connected to his IV line.

Interview of the LN 2 on the morning of 8/7/14 at approximately 10:30 A.M. revealed her understanding of 5/15/14. She stated that on 5/15/14, she relieved LN 1 for a lunch break. She did an assessment of the patient and noted he was experiencing pain so she provided other pain medications before she could set up his PCA. When she had a moment, she connected his PCA. She stated it was a busy day and there were a lot of things going on at the same time. The LN 2 stated that the entire staff in Recovery Room received reminders of how to connect PCAs and hanging IV lines. The LN 2 stated that PCA settings required 2 LNs to check before connection.

In an Event Report filed by LN 2, the LN 2 stated that while she was attempting to connect the PCA she was also giving Patient 1 IV push pain medications because of his pain levels. At the same time, an X-Ray Tech was there taking multiple x-rays and the Lab Tech came to draw blood.

Review of the physician's progress notes dated 5/16/14 revealed that he was aware of the incident and had followed through with the appropriate staff members.

A review of the facility policy (adapted from Mosby's Skills) titled, "Medication Administration: Piggyback, Intermittent Infusion Sets, and Mini-Infusion Pumps", noted: 3) Assess patency of the patient's existing IV infusion line or saline lock; 4) Assess IV insertion site for signs of infiltration or phlebitis: redness, pallor, swelling, and tenderness on palpation."

Based on record review, staff interviews, and facility policy review, the facility failed to administer intravenous medications according to medical staff policies and procedures.

Findings include:

A record review of Patient 1 revealed he received an elective bilateral knee replacement surgery on 5/15/14. When he arrived at the Recovery Room, he was experiencing 10/10 pain (on a scale of 1 least pain to 10 most pain). The licensed nurse, LN 1, provided pain medications via intravenous (IV) push. The Patient 1 also had orders for a Patient Controlled Analgesic, which allowed him to push a button to receive pain medication when he needed it. The LN 1 went on a lunch break and was relieved by LN 2. The LN 2 cared for Patient 1, who continued to complain of extreme pain. The LN 2 started his PCA and thought she connected his IV tubing. Approximately 3 hours after arriving in the Recovery Room, Patient 1 was transferred to the Medical Surgical (Med Surg) floor. The LN 1 brought Patient 1 to the floor and provided a hand off report to LN 3. As LN 3 did her assessment of Patient 1, she discovered the PCA had not been connected to Patient 1's IV line.

Interview of LN 3 on 8/6/14 at approximately 2:30 P.M. found that she was assisting Patient 1's primary nurse on 5/15/14 when he was transferred to the Med Surg floor. The LN 3 stated that she performed a head to toe assessment when Patient 1 arrived on the floor. As she removed his blankets, she discovered the IV tubing was not connected to the patient. She stated the patient was experiencing a lot of pain ranging from 7-9/10. The LN 3 notified Patient 1's primary nurse and notified the physician.

Interview of LN 2 on the morning of 8/7/14 at approximately 10:30 A.M. revealed that she relieved LN 1 during a lunch break. The LN 2 stated she has received training on IV medication administration. She also noted that she frequently connected PCAs - approximately 5 times within a 12 hour shift. The LN 2 stated that PCAs required 2 checks by 2 licensed nurses. Patient 1's PCA had been checked twice by licensed nurses when it was connected in the Recovery Room. The PCA was again checked twice when Patient 1 was handed off to the Med Surg floor, when the disconnection was discovered. The LN 2 stated the Recovery Room was very busy on 5/15/14. She stated that she had been interrupted several times while in the process of connecting the PCA. She stated she now ensures full concentration without any interruptions when she connects PCAs.

Interview of the Recovery Room Nurse Manager, NM, on the afternoon of 8/6/14 at approximately 1:00 P.M. revealed that the LNs in the Recovery Room were required to receive training in IV medication administration. The NM was responsible to ensure staff were prepared and trained. The NM reported that LN 2 was a call-in nurse and wasn't available for an interview as she was in the mainland and not on the island. The LN 2 previously worked in the Recovery Room, wasn't around for a period of time, then returned to the facility as a call-in nurse. The NM reported that LNs in the Recovery Room practiced IV medication administration on a daily basis because of the specialized nature of their unit.

On the morning of 8/7/14, a personnel record review of the training for LNs working in the Recovery Room found LN 2 was not validated for PCA epidural/peripheral skills checklist. Interview of the Human Resources staff revealed the definition of validation was when a LN was checked off and found to be competent at that skill. The LN 2 started 4/22/14 and was supposed to be validated for PCA epidural/peripheral skills by 7/22/14.

Interview of the Quality Coordinator on the morning of 8/7/14 revealed that LNs received training prior to working independently. The Quality Coordinator stated the facility didn't have a policy for training nurses to insert/maintain IV lines but rather followed a training schedule. The LN 2 was an experienced LN and therefore didn't receive training like a new nurse without experience. However, the NM did not follow policy by validating her skills for PCA management.