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Based on record review and interview, the facility failed to provide requisite information in the written notification of grievance resolution. The deficient practice is evidenced by failure to include the results of the investigation in 1 (Patient #2) of 1 reviewed grievance letters.

Findings:

Review of the grievance submitted by Patient #2 revealed the patient was not satisfied with his care while admitted 07/07/2023 through 07/14/2023. The complaint stated, "it took nurses 1 hour to 1 ½ hour to assist him," "Physical Therapy got him up twice, and the rest of the days they set him up in the recliner next to the bed for 6-8 hours," "Lee from Case Management did not do anything to help him," "He also spoke the charge nurse on 7 East and feels nothing was resolved," and "maybe if my pain was better controlled, I would have been able to do more."

Review of the investigation revealed S5CM from Care Management reviewed the medical record and contacted the patient by phone on 08/17/2023 and discussed his care. S6TS from Therapy Services reviewed the medical record and contacted the patient by phone on 08/18/2023 and discussed his care. S4RN from Nursing Services reported that she spoke with Patient #2 about the administration of the pain medication while he was in the hospital. S4RN did not document the date and time of the encounter and did not document if a review of the pain medication administration was performed.

Review of the discharge planning for Patient #2 revealed documentation the patient was told of the insurance refusal of inpatient rehabilitation services and his conversations with the surgeon. Patient #2 agreed to go home with home health from the company who provided his care prior to admission. It was also verified the patient had a walker and wheelchair at home.

Review of the therapy services for Patient #2 revealed the patient received physical therapy and occupational therapy each day as ordered.

Review of the orders for Patient #2 revealed the patient had orders for the following medications for pain:
-Oxycodone-acetaminophen (Percocet); 1 tablet; oral; every 4 hours PRN pain score 8-10," and
-Hydromorphone (Dilaudid) injection; 0.6 mg; every 4 hours for pain not relieved with oral medication. And included instructions, "If PO pain med is also ordered, use IV opioid only if one of the following conditions exist: . . . 3) Pain unrelieved by oral PRN med 1 hour after administration."

Review of the pain assessments and medication administration revealed the following:

On 07/08/2023 at 7:59 a.m., the patient reported pain score of 10 (ten). The patient had last received hydrocodone at 2:53 a.m. and oxycodone at 6:07 a.m. Pain medication was not administered.

On 07/08/2023 at 12:49 p.m., the patient reported pain score of 8 (eight). The patient had last received hydrocodone at 8:57 a.m. and oxycodone at 11:43 a.m. Pain medication was not administered.

On 07/09/2023 at 10:05 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 8:12 a.m. and oxycodone at 5:13 a.m. Pain medication was not administered.

On 07/10/2023 at 10:54 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/10/2023 at 11:29 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/11/2023 at 8:16 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 9:31 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 11:11 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 10:11 a.m. Pain medication was not administered.

On 07/12/2023 at 10:51 a.m., the patient reported pain score of 8 (eight). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 6:38 a.m. Pain medication was not administered.

On 07/12/2023 at 3:11 p.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 2:11 p.m. Pain medication was not administered.

In interview on 09/06/2023 at 8:55 a.m., S2AS verified the patient was within the parameters to receive pain medication and it was not administered as ordered.

Review of the letter sent to the patient on 07/21/2023 revealed the "concerns were forwarded to Director of 7 East Nursing, Director of Therapy Services, and the Director of Care Management for review and follow-up." "They have listened to your concerns and apologized for your dissatisfaction." The letter did not include the results of the grievance investigation and did not state if the allegations were substantiated or unsubstantiated.

On 09/06/2023, S1SDQM and S2AS were contacted via email about the letter not providing written notification of the results of their investigation and decision whether or not the allegations were substantiated. At 1:05 p.m. S2AS replied and agreed the letter should have said more. At 3:29 p.m. S1SDQM replied, "Based on the investigation, the allegations were not substantiated. The letter states that our review was concluded and that the Directors involved listened to the patient's concerns and apologized for any dissatisfaction."

Based on record review and interview, the hospital failed to properly investigate medication administration errors. The deficient practice is evidenced by failure to properly review medication administration after receiving a pain medication grievance for 1 (Pt.#2) of 1 reviewed closed grievances.

Findings:

Review of the grievance submitted by Patient #2 revealed the patient was not satisfied with his care while admitted 07/07/2023 through 07/14/2023. The complaint stated, "it took nurses 1 hour to 1 ½ hour to assist him," "Physical Therapy got him up twice, and the rest of the days they set him up in the recliner next to the bed for 6-8 hours," "Lee from Case Management did not do anything to help him," "He also spoke the charge nurse on 7 East and feels nothing was resolved," and "maybe if my pain was better controlled, I would have been able to do more."

Review of the investigation revealed S5CM from Care Management reviewed the medical record and contacted the patient by phone on 08/17/2023 and discussed his care. S6TS from Therapy Services reviewed the medical record and contacted the patient by phone on 08/18/2023 and discussed his care. S4RN from Nursing Services reported that she spoke with Patient #2 about the administration of the pain medication while he was in the hospital. S4RN did not document the date and time of the encounter and did not document if a review of the pain medication administration was performed.

Review of the discharge planning for Patient #2 revealed documentation the patient was told of the insurance refusal of inpatient rehabilitation services and his conversations with the surgeon. Patient #2 agreed to go home with home health from the company who provided his care prior to admission. It was also verified the patient had a walker and wheelchair at home.

Review of the therapy services for Patient #2 revealed the patient received physical therapy and occupational therapy services each day as ordered.

Review of the medications ordered for pain included:

-Oxycodone-acetaminophen (Percocet); 1 tablet; oral; every 4 hours PRN pain score 8-10; and
-Hydromorphone (Dilaudid) injection; 0.6 mg; every 4 hours for pain not relieved with oral medication and included instructions, "If PO pain med is also ordered, use IV opioid only if one of the following conditions exist: . . . 3) Pain unrelieved by oral PRN med 1 hour after administration."

Review of the pain assessments and medication administration revealed the following:

On 07/08/2023 at 7:59 a.m., the patient reported pain score of 10 (ten). The patient had last received hydrocodone at 2:53 a.m. and oxycodone at 6:07 a.m. Pain medication was not administered.

On 07/08/2023 at 12:49 p.m., the patient reported pain score of 8 (eight). The patient had last received hydrocodone at 8:57 a.m. and oxycodone at 11:43 a.m. Pain medication was not administered.

On 07/09/2023 at 10:05 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 8:12 a.m. and oxycodone at 5:13 a.m. Pain medication was not administered.

On 07/10/2023 at 10:54 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/10/2023 at 11:29 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/11/2023 at 8:16 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 9:31 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 11:11 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 10:11 a.m. Pain medication was not administered.

On 07/12/2023 at 10:51 a.m., the patient reported pain score of 8 (eight). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 6:38 a.m. Pain medication was not administered.

On 07/12/2023 at 3:11 p.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 2:11 p.m. Pain medication was not administered.

Review of the letter sent to the patient on 07/21/2023 after closure of the investigation revealed the "concerns were forwarded to Director of 7 East Nursing, Director of Therapy Services, and the Director of Care Management for review and follow-up." "They have listened to your concerns and apologized for your dissatisfaction." The letter did not include the results of the grievance investigation and did not state if the allegations were substantiated or unsubstantiated.

In interview on 09/06/2023 at 8:55 a.m., S2AS verified the patient was within the parameters to receive pain medication and it was not administered as ordered.

On 09/06/2023, S1SDQM was contacted via email about the letter not providing written notification of the results of their investigation and decision whether or not the allegations were substantiated. At 3:29 p.m. S1SDQM verified their investigation found the allegations were not substantiated.

Based on record review and interview, the hospital failed to ensure medications were administered as ordered. The deficient practice is evidenced by failure to administer pain medication as ordered in 2 (#1 and #2) of 5 (#1-#5) reviewed patient records.

Findings:

Review of the hospital policy "Pain Management" effective May 2000, reveals in part:
Patients will be informed that:
-Effective pain relief is an important part of their treatment,
-Their communication of unrelieved pain is essential,
-Health professionals will respond quickly to their reports of pain.
-A goal of the management of pain is to keep pain at a low level to permit optimal bodily function and optimal quality of life.

Patient #1
Review of the grievances revealed on 08/25/2023, Patient #1 submitted a grievance related to his pain medication. Patient #1 complained he was never given the Dilaudid ordered for his severe pain.

Review of the medical record for Patient #1 revealed admission on 08/23/2023 for decompression hardware removal from L5-S1 and discharged on 08/24/2023.

Review of the medications ordered for pain included:
-Oxycodone 15mg; Oral; Every 4 hours PRN for pain score 1-3;
-Hydromorphone (Dilaudid) 1mg; Every 2 hours PRN; IV route; PRN reason- Pain Score 4-7; and
-Hydromorphone -(Dilaudid) 2mg; Every 2 hours PRN; IV route; PRN reason- Pain Score 8-10.

On 8/23/2023 at 3:19 p.m. the patient reported pain score of 6 and at 9:31 p.m. the patient reported a pain score of 8. Oxycodone was given each time.

On 8/24/2023 at 7:38 a.m. the patient reported a pain score of 7, at 1:34 p.m. the patient reported a pain score of 7, and at 5:46 p.m. the patient reported a pain score of 8. Oxycodone was given each time.

In interview on 09/06/2023 at 10:51 a.m., S3CI verified the patient was supposed to get the hydromorphone for any pain score of 4 or greater. She also verified there were no communication orders noted in the medical record to indicate the nurse had consulted with the physician about a trial of the oral medication for effectiveness.

Patient #2
Review of the grievances revealed Patient #2 submitted a grievance alleging his pain medication was not given as ordered.

Review of the medical record for Patient #2 revealed admission on 07/07/2023 for right hip arthroplasty and discharged on 07/14/2023.

Review of the medications ordered for pain included:
-Oxycodone-acetaminophen (Percocet); 1 tablet; oral; every 4 hours PRN pain score 8-10; and
-Hydromorphone (Dilaudid) injection; 0.6 mg; every 4 hours for pain not relieved with oral medication and included instructions, "If PO pain med is also ordered, use IV opioid only if one of the following conditions exist: . . . 3) Pain unrelieved by oral PRN med 1 hour after administration."

Review of the pain assessments and medication administration revealed the following:

On 07/08/2023 at 7:59 a.m., the patient reported pain score of 10 (ten). The patient had last received hydrocodone at 2:53 a.m. and oxycodone at 6:07 a.m. Pain medication was not administered.

On 07/08/2023 at 12:49 p.m., the patient reported pain score of 8 (eight). The patient had last received hydrocodone at 8:57 a.m. and oxycodone at 11:43 a.m. Pain medication was not administered.

On 07/09/2023 at 10:05 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 8:12 a.m. and oxycodone at 5:13 a.m. Pain medication was not administered.


On 07/10/2023 at 10:54 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/10/2023 at 11:29 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 6:56 a.m. and oxycodone at 9:14 a.m. Pain medication was not administered.

On 07/11/2023 at 8:16 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 9:31 a.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 6:02 a.m. Pain medication was not administered.

On 07/11/2023 at 11:11 a.m., the patient reported pain score of 9 (nine). The patient last received hydrocodone on 07/10/2023 at 11:47 p.m. and oxycodone on 07/11/2023 at 10:11 a.m. Pain medication was not administered.

On 07/12/2023 at 10:51 a.m., the patient reported pain score of 8 (eight). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 6:38 a.m. Pain medication was not administered.

On 07/12/2023 at 3:11 p.m., the patient reported pain score of 10 (ten). The patient last received hydrocodone at 9:53 a.m. and oxycodone at 2:11 p.m. Pain medication was not administered.

In interview on 09/06/2023 at 8:55 a.m., S2AS verified the patient was within the parameters to receive pain medication and it was not administered as ordered.