HospitalInspections.org

Based on review of hospital policy, grievance file reviews, and staff interviews, the hospital staff failed to provide a written response of a grievance to a patient or patient representative per hospital policy for 4 of 6 grievance files reviewed (Pt #6, 4, 3, 8)

The findings include:

Review of the hospital's policy, "Patient Grievance Procedure", dated January 2012, revealed "...Patient Grievance - A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP)... ." Further review revealed "...Responsibility to Respond....5. In the case of a grievance, most situations will be resolved and the patient notified of the resolution by letter from the Patient Relations Representative or Department Director within seven (7) days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the evaluation and investigation into the grievance, and the date of completion (indicated by the date of the letter to the patient)...."

1. File review on 05/01/2014 of a "Patient Relations Worksheet" revealed a complaint related to Pt #6 stating the "...patient was not discharged correctly. ..." received on 09/09/2013. Review revealed the situation was not resolved by staff on hand. Further review revealed "...Status: Closed....09/11/2014. File review revealed no documentation of a follow-up letter to address the grievance and resolution.

Interview on 05/01/2014 at 1420 with Administrative staff #1 revealed "There were no final letters for these grievances. We realize we have a problem."

2. File review on 05/01/2014 of a "Patient Relations Worksheet" revealed a telephone call to Unit Manager #1 on 03/22/2014 from Pt #4's husband that "...they could not believe what he described as the care his wife received here (named hospital)....his wife was sent here and was here for two days and got nothing from being here. He stated that his wife was not seen by a Doctor and that she did not have medications for 2 days and how could they (the hospital) keep her for two days and treat her like she was treated. ..." Further review revealed on 04/30/2013, Pt #4 called, stating she would not pay the bill because "...she did not get proper treatment while she was here (the hospital). That she did not see (physician name). I told her according to her chart she and (physician name) had a conversation about her medications. She said that was not true. She also said she did not get any discharge instructions. ..." Review revealed the situation was not resolved by staff on hand. Further review revealed "...Status: Closed....03/21/2013." Further review revealed no documentation of a follow-up letter to address the grievance and resolution.

Interview on 05/01/2014 at 1420 with Administrative staff #1 revealed the hospital did not consider this situation a grievance and no follow-up letter was sent.



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3. File review on 05/01/2014 of a "Patient Relations Worksheet" revealed a complaint was received on 03/08/2013 from Patient #3 related to patient rights' violations and concerns with care and services provided while an inpatient on 03/03/2013 through 03/09/2013. Review of the file revealed eight patient care issues expressed by the patient. Review revealed the situation was not resolved by staff on hand. Further review revealed "...Status: Closed....03/11/2013. File review revealed no documentation of a follow-up letter to address the grievance and resolution.

Interview on 05/01/2014 at 1420 with Administrative staff #1 revealed "There were no final letters for these grievances. We realize we have a problem."



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4. File review on 05/01/2014 of a "Patient Relations Worksheet" revealed a complaint was received on 04/23/2012 from Patient #8 related to patient rights' violations and concerns with care and services provided in the emergency department on 03/23/2012. Review of the file revealed a three page typed letter dated 04/20/2012 from Patient #8. Review revealed the situation was not resolved by staff on hand. Further review revealed "...Status: Closed....04/23/2012. File review revealed no documentation of a follow-up letter to address the grievance and resolution.

Interview on 05/01/2014 at 1420 with Administrative staff #1 revealed "There were no final letters for these grievances. We realize we have a problem."

Based on hospital policy review, open medical record review, and staff interviews the nursing staff failed to ensure that orders for restraint and/or seclusion were obtained from a physician or other licensed practitioner for 1 of 3 patients restrained (#16).

The findings include:

Review of hospital policy, "Document Name: SAFRS.DOC" titled "Safety - Restraint" revised " ...1/14 ", "Date Approved: January, 2014" revealed, "... 2) The following are required when a restraint intervention for non-violent/non-self-destructive behavior to prevent interference with medical/therapeutic treatment: a) Order within one hour by physician/PA/nurse practitioner who is responsible for care of the patient and has a working knowledge of hospital policy b) attending physician consulted as soon as possible if attending physician did not order the restraint c) order renewed by physician/PA/nurse practitioner daily, based on assessed need to continue use of restraint (no standing order or PRN orders), with face to face assessment within 24 hours. Page 4 of 10...".

Open medical record review on 05/01/2014 of patient #16 revealed a 79 year-old male admitted on 04/19/2014 for bradycardia. Review of patient #16's restraint/seclusion documentation dated 04/26/2014 at 2000 revealed the patient was placed on bilateral soft wrist restraints. Record review revealed patient #16 continued to be in bilateral soft wrist restraints until 04/27/2014 at 0600. Further record review on 04/26/2014 at 1930 staff obtained a verbal order from the physician for bilateral wrist restraint. The "rationale requiring restraint" were "attempting to remove lines/catheters/tubes" and "maintain placement of lines/catheters/tubes". Further record review revealed no physician authenticated the order for Patient #16's restraint from 04/26/2014 at 2000 to 04/27/2014 at 0600 (10 hours without a physician's order).

Record review revealed on 04/30/2014 at 0800 patient #16 was placed on bilateral soft wrist restraint. The "rationale requiring restraint" were "attempting to remove lines/catheters/tubes" and "maintain placement of lines/catheters/tubes". Record review revealed patient #16 continued to be on bilateral soft wrist restraints until 05/01/2014 at 0000, time of the removal of the restraint. Further record review revealed no physician order for patient #16's restraint from 04/30/2014 at 0800 to 05/01/2014 at 0000 (approximately 16 hour without a physician's order).

Interview with Nurse Manager #1 on 05/01/2014 at 1100 revealed a written order from the physician is required for the use of restraint and/or seclusion. Interview revealed no evidence of a physician's orders for restraint/seclusion for Resident #16 performed on 04/26/2014 at 2000 to 04/27/2014 at 0600 and 04/30/2014 at 0800 to 05/01/2014 at 0000.

The facility staff failed to analyze, implement and monitor strategies for improvement of adverse patient events for 3 of 3 adverse events reviewed (Patient #22, #5, & #7).
The findings include:
Review of the hospital's policy "Sentinel Event" dated January 2012 revealed "A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called 'sentinel' because they signal the need for immediate investigation and response...Root Cause Analysis (RCA) is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event...The event investigation for analysis progresses from special causes in clinical processes to common causes in organization processes and systems and identifies potential improvements in these processes or systems that would tend to decrease the likelihood of such events in the future or determines, after analysis, that no such improvement opportunities exist...The action plan is the product of the root cause analysis. It includes the strategies that the health system intends to implement in order to reduce the risk of similar events occurring in the future. The plan will include: specific actions for improvement, time line, measure(s) of effectiveness, and individual(s) responsible for implementation..."
1. Review of the RCA (Root Cause Analysis) Summary Event #13-3310 revealed an event was filed on 11/24/2013 for Patient (Pt) #22. Review of the event revealed a 54 year old "readmitted within 48 hours after cardiac cath (catheterization) and sten (stent) placement for repeat cardiac cath, thrombectomy and additional stents." Continued review revealed the patient was unable to fill a prescription for Brilinta (antiplatelet to prevent clots), a medication that required pre-authorization by the physician. Continued review revealed "The discharge occurred on a Saturday. During the week the medication is filled in the retail pharmacy, but this is not possible on the weekend..." Summary of the strategies for improvement revealed a process for ensuring patients discharged on weekends will have medications available at discharge. Continued review revealed no evidence of ongoing monitoring of the measures of effectiveness of the corrective action plan.
Interview on 05/01/2014 at 1100 with Administrative Staff #2 revealed no ongoing monitoring of the measurement of effectiveness of the strategies for improvement or corrective action plan. Interview confirmed the facility staff failed to implement and monitor the corrective action plan of an adverse patient event.
Interview on 05/01/2014 at 1110 with Administrative Staff #3 revealed no evidence of ongoing monitoring of the measure of effectiveness of the corrective action plan. Interview confirmed the facility staff failed to implement and monitor strategies for improvement of adverse patient events.
2. Review of the RCA Summary Event # (no number listed) revealed an event was filed on 02/28/2013 for Patient #5. Review of the event revealed an 80 year old with abdominal distention who vomited during nasogastric (NG) tube insertion by a Student Nurse and Nursing Instructor. Continued review revealed the patient "became unresponsive, rapid response called immediately (agonal breathing and presence of pulse), anesthesia intubated patient and patient was transferred to ICU (intensive care unit)..." Continued review identified "Strategies for Improvement" included the primary nurse for the patient will be present when a student and instructor are performing an invasive procedure. Continued review revealed no measuring and ongoing assessment of the effectiveness of the strategies for improvement or correction action plan.
Interview on 05/01/2014 at 1100 with Administrative Staff #2 revealed no ongoing monitoring of the measurement of effectiveness of the strategies for improvement. Interview confirmed the facility staff failed to implement and monitor strategies for improvement of adverse patient events.
Interview on 05/01/2014 at 1110 with Administrative Staff #3 revealed no evidence of ongoing monitoring of the measure of effectiveness of the strategies for improvement. Interview confirmed the facility staff failed to implement and monitor strategies for improvement of adverse patient events.
3. Review of the RCA Summary Event #13-443 revealed an event was filed on 02/16/2013 for Patient #7. Review of the event revealed a 78 year old was found "on floor in front of recliner... Pt. stated her feet slipped and she then slid down from the chair to the floor, landing on her buttocks..." Continued review revealed "..X-ray showed minimally displaced fracture of the left distal radius with probably intra-articular extension..." Continued review revealed the identification of strategies for improvement included review of falls for compliance with use and activation of exit alarms and non-slip slippers and rounding by nurse managers to ensure compliance. Continued review revealed no evidence of ongoing monitoring of the measures of effectiveness or corrective action plan.
Interview on 05/01/2014 at 1100 with Administrative Staff #2 revealed no ongoing monitoring of the measurement of effectiveness of the strategies for improvement. Interview confirmed the facility staff failed to implement and monitor strategies for improvement of adverse patient events.
Interview on 05/01/2014 at 1110 with Administrative Staff #3 revealed no evidence of ongoing monitoring of the measure of effectiveness of the strategies for improvement. Interview confirmed the facility staff failed to implement and monitor strategies for improvement of adverse patient events.
NC00087688, NC00088746