HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each patient was informed of their right to file a grievance, including whom to contact internally to file a grievance. This was evidenced by the "Patient Rights and Responsibility" form, given to all patients upon admit the hospital, having the wrong contact number for the hospital's compliance hotline. Findings:

Review of the form titled, "Patient Rights and Responsibility" revealed that that patients may file a grievance by a nursing supervisor, administrative personnel or by calling the compliance hotline at (number listed).

Upon calling the above compliance hotline number, it was a recording stating that it was the compliance hotline for another local hospital.

On 04/15/15 at 1:15 p.m., interview with S2CNO confirmed that the contact information for the hospital's compliance hotline was not the correct number. S2CNO further confirmed that this incorrect number was given to all patients upon admit to the hospital in their admission packets.

Based on record review and interview, the hospital failed to establish a grievance process for prompt resolutions of a patients grievance as evidenced by the hospital's policy not having specified time frames for review of the grievance and the provision of a response. Findings:

Review of the hospital policy titled Service Recovery/Complaint Policy (effective date October 2008) revealed in part that whoever receives the complaint shall immediately investigate the complaint and attempt to resolve. The complaint should then be filled out and forwarded to Service Coordinators. This policy did not specify time frames for review of the complaint/grievance and the provision for a response.

On 04/15/15 at 10:45 a.m., an interview with S2CNO confirmed that the above policy was the current policy that the hospital used to resolve grievances and complaints. After reviewing the policy, S2CNO confirmed the policy did not specify time frames for reviewing complaints/grievances and the provision for a response. S2CNO further stated that the hospital tries to resolve all grievances as soon as possible, but there were no time frames that were to be followed.

Based on record review and interview, the hospital failed to provide patients with written notice of its decision regarding grievances which 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. This was evidenced by no written notices provided to 3 of 3 patients (#22, #23, #24) who filed grievances in 2015. Findings:

Review of the hospital policy titled Service Recovery/Complaint Policy (effective date October 2008) revealed in part that whoever receives the complaint shall immediately investigate the complaint and attempt to resolve. The complaint should then be filled out and forwarded to Service Coordinators. The Service Coordinators will compile this information monthly to be able to trend and track any recurring complaints. This policy did not address the requirement that written notices would be provided to the patients after the resolution of the grievances.

Review of the hospital's grievance log revealed that three grievances had been filed in 2015. Further review of the grievances and investigations revealed no evidence that upon resolution of the grievance, a written notice had been provided to the patients who filed the grievances, which included 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.

On 04/15/15 at 10:45 a.m., an interview with S2CNO confirmed that the above policy was the current policy that the hospital used to resolve grievances and complaints. S2CNO revealed that phone calls are usually made to follow-up with the person who filed the grievance, but not always. S2CNO revealed that written notices are not provided after the resolution of the grievances. S2CNO further revealed that it was not the hospital's procedure to mail written notices of the hospital's decision regarding grievance investigations.

Based on record reviews and interviews, the hospital failed to ensure a RN (Registered Nurse) evaluated the nursing care of each patient as evidenced by:

1) failure to ensure that the charge nurse was competent to operate the defibrillator on the crash cart.

2) failure to ensure that four Certified Nurse Aides (CNA) (S10CNA, S11CNA, S12CNA, S13CNA) who provided one to one observations of a patient who was admitted under a Physician Emergency Certificate (PEC) (#15) had received training in the care of psychiatric patients.

3) failure to provide continuous telemetry monitoring for 6 of 6 (#11, #17, #18, #19, #20, #21) patients who had physician orders for telemetry (cardiac) monitoring. This failed practice was evidenced by no nursing staff/ monitor technician assigned to monitor the patient telemetry monitors for the patients with physician orders for cardiac monitoring.

Findings:

1) Failure to ensure the charge nurse was competent with the defibrillator.

On 04/14/15 at 10:30 a.m., S9RN provided a tour of the medical/surgical unit. Observations during this time revealed a crash cart was located in a hall closet. Further observations revealed a Medtronic Lifepak 20 defibrillator was on top of the crash cart. Review of a daily log on top of the cart revealed that it was checked that morning by S9RN. At that time, interview with S9RN revealed that she just checks the crash cart for the supplies, but does not check the defibrillator or run a test strip to ensure it is working properly. S9RN further added that she had never been trained to use the defibrillator. Further interview with S9RN revealed that she was the charge nurse for the day shift and was the only RN working with two LPNs on the unit.

On 04/14/15 at 10:45 a.m., interview with S2CNO revealed that S9RN should have been trained to operate the defibrillator on the crash cart.


2) Failure to ensure that CNAs who work with psychiatric patient receive training.

Review of the medical record for patient #15 revealed the patient presented to the Emergency Department on 04/12/15 with an overdose and suicide attempt. Further review revealed the patient was PEC'd and admitted to the medical floor on 04/12/15 at 11:15 p.m. with one to one observations per the CNA who was sitting in the room with the patient.

The medical record revealed that four different CNAs provided one to one observations of the psychiatric patient until her discharge on 04/13/15 at 4:55 p.m. Review of the training files for S10CNA, S11CNA, S12CNA and S13CNA revealed no evidence that they had received any training related to the care of psychiatric patient (crisis prevention).

On 04/15/15 at 10:15 a.m., interview with S2CNO confirmed that the CNAs who provided one to one observations of patient #15 had no training related to psychiatric patients and crisis prevention. S2CNO further confirmed that the hospital had no policies and procedures to address formal training for staff who provide care to psychiatric patients, such as crisis prevention.

3) failure to provide continuous telemetry monitoring for the patients with physician orders for cardiac monitoring.

An observation of the telemetry monitors at the nurse ' s station on 4/14/2015 at 11:30 a.m. revealed patient ' s #11, #17, #18, #19, #20, #21 were on telemetry monitor. Further observation of the telemetry monitors at the nurse ' s station revealed that there was no nursing staff/telemetry technician monitoring the telemetry monitors.

In a face to face interview on 4/14/2015 at 11:40 a.m. with S14LPN (Licensed Practical Nurse) stated that the nursing staff was responsible for monitoring the telemetry monitors. S14LPN further stated that if there were no nursing staff in the nurse ' s station the clerk was there and could notify them of a problem.

In a face to face interview on 4/14/2015 at 11:45 a.m. with S17Clerk confirmed that she had no training to monitor telemetry monitors. S17Clerk further stated that when there are no nurse ' s in the nurse ' s station and a telemetry monitor would alarm she could notify the nurse ' s by a beeper system.

A review of patient #11 ' s medical record revealed the patient was admitted on 4/9/2015 with a diagnoses of Pulmonary Edema, and Pleural Effusion and had admit orders for telemetry with vital signs every 4 hours.

A review of patient #17 ' s medical record revealed the patient was admitted on 4/12/2015 with a diagnosis of Chest Pain and had admit orders for telemetry with vital signs every 4 hours.

A review of patient #18 ' s medical record revealed the patient was admitted on 4/13/2015 with a diagnosis of Chest Pain and had admit orders for telemetry with vital signs every 4 hours.

A review of patient #19 ' s medical record revealed the patient was admitted on 4/14/2015 with a diagnosis of Angioedema and had admit orders for telemetry with vital signs every 4 hours.

A review of patient #20 ' s medical record revealed the patient was admitted on 4/13/2015 with a diagnosis of Dehydration, and Hypotension and had admit orders for telemetry with vital signs every 4 hours.

A review of patient #21 ' s medical record revealed the patient was admitted on 4/13/2015 with a diagnosis of COPD and had admit orders for telemetry with vital signs every 4 hours.

A further observation of the telemetry monitors at the nurse ' s station on 4/14/2015 at 1:30 p.m. revealed that there was no nursing staff/telemetry technician monitoring the telemetry monitors.

A review of the policy titled, " Telemetry Monitoring " , as provided by S2CNO as the most current, revealed in part: The Registered Nurse shall provide cardiac rhythm and rate analysis and institute indicated assessments and interventions associated with cardiac rate or rhythm disturbances.

In a face to face interview on 4/15/2015 at 10:00 a.m. with S2CNO confirmed the nurse ' s should be monitoring the telemetry monitors at all times. S2CNO further stated that the clerk was not trained in telemetry monitoring and should not be left at the nurse ' s station to monitor the patient ' s.









25119

Based on policy review, observation and interview, the hospital failed to ensure patient medical records were stored in a location where the medical records were protected from damage by fire as evidenced by storage of patient medical records (2008 and prior) in an outdoor metal storage building that had no fire protection. 982 of the patient records (963 inpatient records and 19 death records) stored in the metal building had not been backed up/scanned into the hospital's electronic medical record system.
Findings:
Review of the hospital policy, title: Record Retention for Medical Records, Policy Number: F11; Policy Effective: August 2006; Revision: June 2012, May 2013, revealed in part:
It is the policy of this hospital to have an ongoing, coordinated administrative effort to systematically manage our records from inital creation to final disposition. Our records management program includes, but is not limited to: the legal disposition of obsolete records; the identification and administration of and access to records of enduring value; filing and indexing systems; the use of computer or other technology in information creation, manipulation and storage; the storage and management of inactive records no longer needed for conduct of day-to-day business in the office; the oversight of the creation and use of forms, correspondence and other records and the provision for protection of vital records.
Definitions:
Record: The enduring proof of business functions. Begins at the end of the document stage. All records were, at one time, documents.
Records of enduring value (archival records): Those records worthy of permanent retention and special administration because of the importance of the information they contain for continuing administration because of the importance of the information they contain for continuing administrative, legal, or fiscal purposes, or for historical or other research.
Vital records: Those records essential to the organization's continuing operation. Includes information that would be needed to resume and continue the operations of the government after a major disaster such as a fire or flood, to protect the legal and financial interests of the organization and preserve the rights of the people served.
482.24(b)1: Medical records will be retained in their original or legally reproduced form for a period of at least 10 years for adults.
Medical records on patients 19 years or older at this hospital are retained in their original or legally reproduced form for 10 years post discharge or outpatient date of service. Records on patients 18 years or less are maintained for either 10 years post discharge or until the patient reaches age of majority plus 10 years, whichever is greater. Death records are placed in the deceased section of the file.
Current schedule:
Active records: 2009 to present date; located in the main file area.
Inactive records: 2008 and prior in binders by medical record number and then broken down by account, 2003 and prior to; located in boxes in the inactive file area.
Review of the hospital policy, title: Destruction of Medical Records, Policy Number: F13; Policy Effective: August 2006; Revision: June 2012, revealed in part:
3. Identify, protect, and preserve archival records. Do not destroy these (birth and death registry information).
5. Identify and preserve medical records of minors until such time they are eligible for destruction.
On 4/13/15 at 2:45 p.m. an observation was made of the outside metal storage buildiing where patient medical records (2008 and prior) were stored. The medical records were stored in covered cardboard boxes on open wood shelves. The building was not equipped to protect the patient medical records from damage/destruction/loss by fire.
In an interview on 4/13/15 at 2:46 p.m. with S4HIMClerk, she confirmed that not all of the above referenced patient medical records had been scanned/backed up into the hospital's electronic medical record system. S4HIMClerk indicated she was not sure how many of the patient medical records had been backed up/scanned into the hospital's electronic medical record system. She agreed the above referenced patient medical records stored in the metal building were not protected from damage/destruction/loss by fire.
In an interview on 4/15/15 at 1:35 p.m. with S2CNO, she indicated 982 patient records (963 inpatient records and 19 death records) stored in the metal building outside had not been scanned/backed up into the hospital's electronic medical record system. She agreed the patient medical records stored in the metal building were not protected from damage/destruction/loss by fire.