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Based on interviews and records review, the facility failed to ensure that staff accurately identified grievances and resolved them timely in 1 of 1 sampled patient (Patient #11).


This deficient practice had the likelihood to cause harm in all patients admitted to the facility.


Findings include:



Review of the complaint and grievance log revealed that there was a complaint dated 10/03/2014 that read as follows:


"Family upset about care and hygiene for patient and the HIPPA rules." (Patient #11)
According to the log the allegations were documented as being a complaint instead of a grievance. Under the follow-up section there was documentation that an email was sent to (key facility staff). There was no documentation of how the complaint was resolved. According to the log the complaint was received and closed on 10/03/2014.


During an interview on 11/20/2014, after 11:05 a.m., with Staff # 12 and 13 revealed that they were some of the staff responsible for the complaint/ grievance process. Staff #12 reported that grievances were more of medical issues and complaints were about food or something brought to them immediately. Staff #12 reported that for grievances they send a letter within 7 days and if they are not able to close it out again within 30 days. Staff #12 reported that she sent a letter requesting more information (10/10/2014), but had not sent a resolution letter. Staff #13 reported that all she had on the complaint was an email explaining what happened.


Review of an email dated 10/03/2014, provided by Staff #13 revealed that Patient #11s' daughter called the Guest services office this afternoon. She complained about poor care received here since her father was admitted 2 weeks ago. She reported that the poor care began on K3 to PCU and is now on K5 (the affected nursing units). They voiced concerns about the patients' blood gases, activity of daily living care, HIPPA concerns and staff attitude. Staff #7 documented in the e-mail that the patient had 6 people at a time cleaning him up. The blood gases were bad because he refused to wear his bipap during the night. The question was posed By Staff #7 if it had anything to do with the complainant being an ex-employee ...


Review of the clinical record on Patient #11 revealed he was discharged from the hospital on 10/06/2014.


Review of a grievance letter dated 10/10/2014, revealed that Staff #12 sent the family a letter which mentioned they "were made aware of several issues that were brought forward during your stay, we were not aware of any issues that were ignored or not acted on as soon as possible by the patient care staff in order to make sure that you received very good care. It is very important to all of us that we have a full understanding of what we could do better, and any specifics from you would be greatly appreciated." A request was made for the family to call the facility. The letter did not outline an investigation or resolution process.


Review of the facility's complaint and grievance policy dated 05/30/2014, revealed:
Grievance - A formal or informal written (written communication is always considered a grievance regardless of method) or verbal complain (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or patient's representative, regarding any of the following:


The patient's care,
Abuse or neglect,
Issues related to the organization's compliance with the CMS Hospital Conditions of Participation (COP), or
A Medicare beneficiary billing complaint related to rights and limitations ...


When the patient care complaint cannot be resolved at the time of the complaint by staff present, its postponed for later resolution, requires investigation, and/or required further actions for resolution then the complaint is a grievance.
Processing a Grievance


The patient and or patient's representative will receive written communication from Guest Services or Administration within 7 days of the receipt of the grievance.


Communication with the patient or patient representation must include in the resolution letter:
A.Name of hospital contact person
B.Steps taken to investigate the process
C.Results of grievance process
D.Date of completion.
Note: when a grievance will not be resolved or the investigation is not or will not be completed within the 7- daytime frame, the patient or patient's representative will be informed within those 7 days that follow will be provided in the form of a written response within 30 days of receipt or within forty-five days if special circumstances require an extension.

Based on observations, interviews and documents review, the facility failed to ensure confidential patient information was discussed in privacy.


This deficient practice had the likelihood to affect all patients admitted into the facility.


Findings include:



During a confidential interview it was reported that staff were discussing personal patient information during shift reports and could be overheard.


During an interview on 11/20/2014, after 11:55 a.m., Staff #14 reported they had been doing walking patient rounds for about 2 months now. While giving report they leave the patient's door open. She never thought about anyone overhearing them.


During an observation and interview on 11/20/2014, after 12:00 p.m., Staff #15 reported that they give part of the report in the patient's room and sometimes in an Alcove outside the patient's room. An observation of the alcove revealed it was an open area outside the patient's rooms and was not enclosed from anyone passing by in the hallway.


Review of the facility's policy named "Patient Rights and Responsibilities" dated 09/18/2014, revealed that the patient has the right to receive confidential treatment of all communications and records and records pertaining to your care and stay in the hospital.

Based on observations, interviews and records review, the facility failed to:


A. ensure patients at risk for skin breakdown and with current skin breakdown were turned and repositioned as ordered by the physician and per policy in 3 of 3 patients (Patient #s' 1,10, and 11). The facility failed to ensure complete assessments and continuous nurse monitoring during changes in condition in respiratory status, skin breakdown and changes in bowel pattern in 2 of 2 patients (Patient # 10 and 11).

Refer to tag A0396 for additional information.


B.ensure medications were administered in a safe manner in 1 of 1 patient (Patient #1).

Refer to tag A0405 for additional information.

Based on observations, interviews and records review, the facility failed to ensure patients at risk for skin breakdown and with current skin breakdown were turned and repositioned as ordered by the physician and per policy in 3 of 3 patients (Patient #s' 1,10, and 11).


The facility failed to ensure complete assessments and continuous nurse monitoring during changes in condition in respiratory status, skin breakdown and changes in bowel pattern in 2 of 2 patients (Patient # 10 and 11).


This deficient practice had the likelihood to cause harm in all patients admitted to the medical surgical units.


Findings include:



Review of a stroke/transient ischemic attack admission order set dated 11/16/2014, revealed Patient #1 was an 85 year old female. Patient #1 had diagnoses which included acute mental status and syncope versus transient ischemic attacks.


Review of a physician's order dated 11/17/2014, at 12:48 midnigh,t revealed an order to turn and reposition every two hours.


Review of the admission assessment report dated 11/17/2014, at 4:55 a.m., revealed a Braden scale for predicting pressure sore risk which documented Patient #1was at a moderate risk for pressure sore development. There was also documentation at this time that Patient #1 was repositioned, but there was no documentation as to what position she was in.


Review of daily focus assessment reports revealed the following documentation on staff turning and repositioning:



11/17/2014


At 2:04 p.m., patient in a sitting position;


At 10:00 p.m., (8 hours later), turn every 2 hours selected, but there was no documentation as to what side the patient was on.



11/18/2014


At 2:18 a.m., 4:00 a.m. and 6:01a.m., turn every 2 hours was selected, but there was no documentation as to what side the patient was on.


At 3:41 p.m., the patient was irritated with physical therapy when attempts were made to reposition and at 3:53 p.m. he was on his left side;


At 6:05 p.m. and 6:30 p.m., over 2 hours later he was still on the same side;


At 10:00 p.m., (over 4 hours later) there was documentation he was on the right side;



11/19/2014


At 12:00 midnight, she was on her back and at 12:03 a.m. and 2:00 a.m. on the left side;


At 4:00 a.m., (almost 4 hours later) there was documentation she was on the right side;


At 6:16 a.m., on the left side and this was the last documented turning for this day.



During an observation on 11/19/2014, at 11:00 a.m., (almost 5 hours later) Patient #1 was observed in bed lying on her left hip. While making observations the patient asked for staff to turn her to her other hip.


Review of the Emergency Department Triage Report dated 10/24/2014, revealed Patient #10 presented at 12:36 p.m. with a chief complaint of shortness of breath.


Review of a Pressure Ulcer assessment dated 10/24/2014, revealed Patient #10 was admitted with 3, Stage I pressures ulcers (right heel, left heel and coccyx). The ulcers were described as being red and there was reference made to photos which were taken.


Review of the photos and assessment revealed no documentation of the size of the ulcers. There was no complete assessment of the pressure ulcers.


Review of the admission assessment report dated 10/24/2014, at 9:30 p.m., revealed a Braden scale for predicting pressure sore risk which documented Patient #10 was at a low risk for pressure sore development.


Review of Daily Focus assessment sheets revealed the following documentation on turning and repositioning:



10/25/2014


At 12 midnight, 10 a.m., 12:00 p.m., 2:00 p.m., and 4:00 p.m., there was documentation to turn every two hours. Staff failed to document which side the patient was laying on. Between 6:00 a.m. -10:00 a.m. there was no documentation of the patient being turned.
After 6:00 p.m. on 10/25/2014 and up until 10:00 a.m. on 10/26/2014 there was no documentation of the patient being turned.



10/26/2014


Every two hours from 10:00 a.m. - 6:00 p.m., there was no documentation to turn every 2 hours. Staff failed to document which side the patient was laying on.



10/28/2014

After 5:56 a.m. and up until 10:15 a.m.; after 6:45 p.m. and up until 10:00 p.m. there was no documentation of turning during these time frames.



10/29/2014 -10/30/2014

From 10:00 a.m. on 10/29/2014 to 10/30/2014 at 4:00 p.m. there was no documentation of what side the patient was turned to.


Review of an Emergency Department (ED) dated 09/19/2014, revealed Patient #11 was a 61 year old male presented at 12:08 p.m. with a chief complaint of shortness of breath.


Review of the ED notes revealed Patient #11 had an oxygen saturation of 92 percent on 4 liters of oxygen at 12:16 p.m.


Review of the ED admission physician history and physical dated 09/19/2014 revealed Patient #11 had diagnoses including congestive heart failure, chronic obstructive pulmonary disease versus obstructive apnea, and chronic kidney disease.


Review of an arterial blood gas (ABG, lab test to check how well the lungs move oxygen into the blood and remove carbon dioxide from the blood) dated 09/19/2014 at 1:40 p.m. revealed Patient #11 was on oxygen at 4 Liters per nasal cannula and had an elevated PCO2 (partial pressure of carbon dioxide) of 64.5 (reference range being 35-45). There were places on the lab form for staff to document when the results were reported and they were left blank.


Review of a physician orders dated 09/19/2014 revealed the following:

*At 5:13 p.m., Notify the MD (Medical Doctor) for change in condition;

*At 5:13 p.m., Notify the MD of P (pulse)>130 R (respirations)>30 T (temperature) >38.5, O2 (oxygen) sat < 90 %;

*At 5:15 p.m., Maintain O2 sat at 92 %;

*At 5:15 p.m., Continuous pulse oximetry, Measure and record.


Review of the nursing assessment dated 09/19/2014, at 8:00 p.m.; revealed Patient #11 arrived to the nursing unit at 7:30 p.m. Patient #11 was described with his respirations being unlabored, shallow, tachypnea, wheezing and having diminished breathe sounds. At 9:44 p.m. the oxygen saturation was 92 percent on 3 liters of oxygen per nasal cannula.


Review of Nursing and Respiratory Notes revealed the following:


On 09/20/2014, at 3:03 p.m., (on 3 Liters), 09/21/2014, at 3:14 a.m., (on 3 Liters), 09/21/2014, at 3:33 p.m., (on 2 Liters), and 09/26/2014, at 11:43 a.m., (on 4 Liters) and nebulizer treatments were administered and oxygen saturations were listed as being 91 percent. There was no documentation as to if the low oxygen saturations was before or after the treatment. There was no documentation of the saturation being back up to 92 percent as physician ordered.


On 09/26/2014, at 11:48 p.m., Patient #11 received a nebulizer treatment. The oxygen saturation was at 91 percent and he was on oxygen at 4Liters. There was no documentation of the low oxygen saturation was before or after the treatment. There was no documentation of the saturation being back up to 92 percent as physician ordered. At 12:25 midnight (over 30 minutes later) there was documentation the oxygen saturation was 85-89 percent on 4 Liters of oxygen. Patient #11 was placed on oxygen 40 percent via mask.


On 09/28/2014, at 12:30 p.m., there was documentation the patient continued to be lethargic and it would be addressed with doctor. At 2:30 p.m., there was documentation by nursing that after reviewing the record 1(one) ABG was found (from 09/19/2014) and the CO2 was 64.5. The doctor was notified and will check ABG to assess the CO2 level. Patient will wake but is very drowsy and lethargic. A family stated this was not his norm.


Review of ABG dated 09/28/2014, at 2:56 p.m., revealed Patient #11 had an increased CO2 level of 71.2 (9 days after the first ABG).


Review of nurses notes on 09/28/2014, at 3:15 p.m., the ABG was abnormal and was reported to the doctor ....Patient will be put on a Bipap (a non-invasive ventilator used to assist with keeping the airway open and oxygen saturation levels up). At 5:34 p.m. there was documentation that the patient was without distress. Bipap in place and patient was more alert at this time.


Gastrointestinal status


Review of an admission assessment dated 09/19/2014; 8:00 p.m. revealed Patient #11's last bowel movement (BM) was on 09/18/2014.


Review of nursing notes and intake and output sheets revealed the following:


On 09/23/2014 (5 days after the last BM) there was documentation of Patient #11 having a bowel movement.


On 09/25 /2014 there was documentation of a bowel movement, but there was no description of how it looked.


On 09/26/2014, at 12:42 p.m., there was documentation of a report of constipation on Patient #11. At 2:30 p.m. staff described the abdomen soft, round, and had hypoactive bowel sounds in all quadrants. There was no documentation of Patient #11 having a BM on 09/26/2014 in the notes.


On 09/27/2014, at 7:30 a.m., there was documentation of the abdomen being soft, round, with bowel sounds present in all quadrants. There was also documentation that the wife reported Patient #11 had not had a BM in one week. Nursing staff documented they would make the MD (medical doctor) aware. Wife reports patient was taking scheduled pain meds, explained that is probably the reason for the constipation.


On 09/28/2014, at 7:15 a.m., (over 23 hours later), there was documentation of Patient #11's having a stool which was brown. There was also documentation that the last BM was 09/26/2014. There was no documentation of this on 09/26/2014.


Review of the Medication administration record revealed the following as the first interventions attempted to address the constipation:


Magnesium Hydroxide (30 ml) oral at Bedtime as needed (for constipation). The start date was documented as 09/28/2014, at 8:39 p.m., and the first dose was administered on 09/28/2014, at 9:55 p.m...


Polyethylene Glycol 3350 (one packet) oral once per day. The start date was documented as 09/28/2014, at 9:00 p.m., and the first dose was documented as being administered on 09/30/2014, at 8:55 a.m.


Review of physician progress notes dated 09/30/2014, revealed the following:
"5. Constipation. Will check the patient KUB this morning. If the KUB shows no obstruction will continue Lactulose until he has a bowel movement. If KUB shows no obstruction then monitor patient for small bowel obstruction."


Review of a KUB dated 09/30/2014, performed at 1:13 p.m. and finalized at 3:44 p.m. revealed no documentation of an obstruction.


Review of notes dated 10/01/2014, at 9:00 a.m., revealed Patient #11 received an enema. There was no follow-up on if the enema worked.


Review of the Medication administration record revealed an order for Lactulose (20 gm/30cc) oral every 3 hours. Give if KUB show no obstruction. Give every 3 hours until BM. The start date on the order was 09/30/2014 and the first dose of medication administered the next day on 10/01/2015 at 5:53 p.m.


During an interview on 11/20/2014, after 11:45 a.m., Staff #7 reported there really no nursing protocol for addressing bowel status. She reported any prudent nurse would become concerned after 3 days of no bowel movements.



Skin Breakdown


Review of the nursing admission assessment dated 09/19/2014, at 8:00 p.m., revealed Patient #11 had a Braden pressure sore risk score of 18 (minimal risk).


Review of a daily focus assessment notes revealed the following:


On 09/20/2014, at 7:05 a.m., Patient #11 had a small amount of redness to the coccyx area which was blanchable... There was no documentation of the size of the area.


On 09/21/2014, at 7:00 a.m., there was a small amount of redness to the coccyx and it was blanchable.


On 09/25/2014, at 10:01a.m., there was a Stage IV sacral pressure sore. There was no documentation of an assessment of the sore.


On 09/26/2014, at 2:30 p.m., the Braden Scale score changed to a 15 meaning he was at a low risk. The action taken was a Specialty bed.


On 09/29/2014, at 7:15 a.m., revealed there was a Stage 2 to the coccyx. There was no documentation of the size of the sore. After this documentation there was no assessment found on the sores in the record.


There was no documentation as to if the sacral sore and coccyx sore were the same or a description to track when they healed.


From 09/19/2014-10/06/2014, revealed documentation the patient turned himself. Staff documented 6 times during this timeframe of which side the patient was laying on.


During an interview on 11/19/2014, after 1:00 p.m. and 11/20/2014 after 8:30 a.m., Staff #5 confirmed not being able to find the documented turning/repositioning, skin assessment, respiratory, and lack of documented assessment of bowel status.


Review of a policy named "Risk assessment and Treatment of Pressure Ulcers" dated March 2014 revealed the following:


F. Photographic documentation of ulcers, skin breakdown, or suspected abuse is to be done as part of the admission assessment by the admitting or primary care nurse and placed into the patient's chart. The photograph should include the following information: Patient identification, information, the date and time the photograph was taken, the location of the skin abnormality, measurements of the skin abnormality and the name and credentials of the individual taking the photograph. Photographs should be taken upon admission, when changes are noted during the hospitalization and at discharge. A physician's order is not required to obtain photographic evidence of the condition of the patient for inclusion into the medical record.


II. Staging of Pressure Ulcer

A.Stage I

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence.


B. Stage II

Partial thickness loss of skin layers presenting as a shallow open ulcer with a red-pink wound bed, without slough: may also present as an intact or ruptured serum-filled blister, abrasion, or shallow crater.


D. Stage IV

Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling. A necrotic wound cannot be staged until the wound base is visible.


III. Prevention and Treatment

Patients should be encouraged to ambulate, get out of bed to sit in a chair or turned on a two hour rotation.

Based on observations, interviews and records review, the facility failed to ensure medications were administered in a safe manner in 1 of 1 patients (Patient #1).


This deficient practice had the likelihood to cause harm in all patients admitted to the medical surgical units.


Findings include:


Review of a stroke/transient ischemic attack admission order set dated 11/16/2014, revealed that Patient #1 was an 85 year old female. Patient #1 had diagnoses which included acute mental status and syncope versus transient ischemic attacks.


During an observation on 11/19/2014, at 11:00 a.m., an unlabeled medication cup containing applesauce and white particles was found on the over bed table next to Patient #1's bed. Staff #8 identified the cup as being Patient #1's medications and that the nurse over the patient's care had left the floor for a while.


During an interview on 011/19/2014, at 11:15 a.m., Staff #9 confirmed the cup contained Patient #1's 10:00 a.m. medications. Staff #9 reported that she drew up the medications at 9:52 a.m. and the patient took one bite and it was being left there to see if she would take the rest. Staff #9 identified the medications as being an anti-coagulant medication Plavix and gastrointestinal acid reducer Protonix.


The medications were crushed that is contraindicated, left at the bedside and in an unlabeled cup.


Review of the medication administration record dated 11/19/2014, revealed some of the following medications:


Plavix 75 milligrams tablet orally once a day;
Protonix 40 milligrams, enteric coated delayed release, once a day.


Review of the website www.drugs.com revealed the following about Protonix:

Do not crush, chew, or break the tablet. Swallow it whole. The enteric-coated pill has a special coating to protect your stomach. Breaking the pill will damage this coating.


Review of a policy revised March 2013 named "Guidelines Patient Care Services" revealed the following:


"F. Medications should be given only if the container is clearly labeled. Unlabeled medications should be destroyed and not be returned to a container.

G. The nurse check with Pharmacy before crushing tablets or opening capsules. (List of medications which should not be crushed should be available on each nursing unit) ....
Observe the patient take the medications. Stay with the patient until the drug is swallowed. Return unopened/refused doses to the patient's supply. Destroy unusable refused drugs ...

L ....If any medication is held on the patient, you should also document in the EMR (electronic medical record) under Miscellaneous: (or Downtime MAR, State HELD and reason). Ordering physician was notified. Any orders given at that time. If medications are refused by patient for two consecutive doses, physician should be notified."