HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure the complaint and grievance process was implemented per policy. This has the potential to affect all patients who receive care at the Hospital, with an average daily census of 20 patients per day.

Findings include:

1. The policy titled "Patient Complaint" (revised by Hospital 6/18) was reviewed on 2/21/19. The policy stated "A patient grievance is 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... regarding the patient's care... 3. Director investigates and contacts the patient within 24 hours... Determination letter will be mailed to the patient... A Complaint is considered resolved when the patient is satisfied with the actions taken on his/her behalf....All grievances receive immediate priority and must be investigated with efforts made toward resolution within 48 hours.... will make every attempt to provide a response within seven (7) days of receiving a grievance..."

2. The complaint and Grievance log dated 11/1/18 through 2/10/19 was reviewed on 2/20/19. The top header categories/columns of the log reading from left to right were as follows:

Patient Name; Who filed complaint; Contact info; Date of visit; Date of complaint; Dept; Complaint Summary; Forwarded to; Date; Resolved how?; Date; Letter Sent; Date; Misc; and Follow-up

under the category "Date of complaint" were several grievances with 5 digit numbers listed instead of a date, examples, 43411; 43431 (listed twice for two different grievances); 43447 etc. and and for other grievances there were dates listed. Under the category "Date" listed after the category "Forwarded to" Vice President of Nursing (E #1) stated that was the actual date the complaint was filed. The next category "Date" listed after the category "Resolved how?" E#1 stated that was the date the complaint was closed.

After review of log, it was unable to determine if the patients were contacted within the 24 hour requirement per policy, unless the date the complaint was filed was the same date as the date the complaint was closed and under "Resolved how?" it stated that the patient was contacted.

3. The following deficiencies were identified after review of Grievances listed on the log:

a) Grievance (G#2) reported on 11/21/18, closed on 12/07/18: No determination letter sent, no documentation patient was contacted within first 24 hours, or complaint "resolved when the patient is satisfied with the action taken on his/her behalf" per policy, prior to complaint being closed.
b) G#4 reported on 12/02/19, closed on 12/04/19: No documentation patient was contacted within first 24 hours, or complaint "resolved when the patient is satisfied with the action taken on his/her behalf" per policy, prior to complaint being closed.
c) G#5/Pt #5 reported on 12/13/18, closed on 12/17/18: No documentation patient was contacted within first 24 hours, or complaint "resolved when the patient is satisfied with the action taken on his/her behalf" per policy, prior to complaint being closed. Please see A-0130.
d) G#6 reported on 12/17/18, closed on 12/21/18: No determination letter sent, and no documentation patient was contacted within first 24 hours.
e) G#7 reported on 12/19/18, closed on 12/20/18: No determination letter sent, and no documentation that the Director was notified.
f) G#8 reported on 12/20/18, closed on 12/28/18: No determination letter sent, and no documentation patient was contacted within first 24 hours.
g) G#9 reported on 1/09/19, closed on 1/15/19: No documentation patient was contacted within first 24 hours, or complaint "resolved when the patient is satisfied with the action taken on his/her behalf" per policy, prior to closing complaint.
h) G#13 reported on 1/21/19, closed on 2/12/19: No determination letter sent, and no documentation patient was contacted within first 24 hours.
i) G#14 reported on 1/24/19, closed on 2/12/19: No documentation patient was contacted within first 24 hours, or complaint "resolved when the patient is satisfied with the action taken on his/her behalf" per policy, prior to closing complaint.
j) G #16 reported on 2/08/19, closed on 2/11/19: No determination letter sent, and no documentation patient was contacted within first 24 hours.

4. During an interview conducted with the Director of the Intensive Care Unit (E#3) on 2/20/19 at approximately 3:15 PM and on 2/21/19 at approximately 10:05 AM, E#3 stated that E#3 had spoke with Pt#5 and sent out a determination letter. E#3 stated that the Hospital didn't inform Pt#5 about the investigation or ask if Pt#5 was satisfied before closing the complaint.

5. During an interview conducted with E#1 on 2/21/19 at approximately 1:00 PM, E#1 confirmed the above findings and stated that the complaints were not investigated within 24 hours and lacked documentation that the patients were satisfied with the investigations.

Based on document review and interview, it was determined in 1 of 10 (Pt#5) patients' records reviewed, the Hospital failed to ensure the patient was involved in the development of the pain management plan per policy. This has the potential to affect all patients who receive care by the Hospital, with an average daily census of 20 patients.

Findings include:

1. The policy titled "Pain Assessment and Reassessment" (revised by Hospital on 5/18) was reviewed on 2/20/19. The policy stated "... respect and support the patient's right to optimal pain assessment and management... will also address the appropriateness and effectiveness of pain management... 4. Pain Scales... i. Uses a 0-10 numeric value..."

2. The clinical record of Pt#5 was reviewed throughout the survey on 2/20/19 and 2/21/19. Pt#5 presented to the Emergency Department with complaint of chest pain on 12/5/18. Pt #5 was admitted to the Post Critical Care Unit on 12/6/18 and underwent a Laparoscopic Cholecystectomy surgery (removal of gallbladder via a scope) on 12/7/18. On 12/6/18 the Physician ordered Acetaminophen 650 mg (milligrams) for mild pain (rated at 1-3)/fever and Ibuprofen 400 mg for mild pain (rated at 1-3)/fever. The Physician's orders stated that if the Acetaminophen was ineffective then give Dilaudid (narcotic medication to treat moderate to severe pain) 0.5 mg intravenously every 4 hours as needed for moderate pain (rated at 4-6). Pt #5's record noted on 12/8/18 between 3:15 AM and 3:29 AM that Pt#5's pain was assessed at a 6/10 and Ibuprofen 400 mg was administered. A Physician order was obtained on 12/8/18 at 6:47 AM for Norco (narcotic medication to treat moderate to severe pain) 5/325 mg as needed for moderate pain (rated at 4-6). The record noted on 12/8/18 between 7:00 AM and 7:14 AM that Pt#5's pain was assessed at a 7/10 and no medication was administered. On 12/8/18 between 7:30 AM and 7:44 AM Pt#5's pain was assessed at a 7/10 and no pain medication was administered. On 12/8/18 between 8:00 AM and 8:14 AM Pt#5's pain was assessed at a 7/10 and Norco 5/325 mg was administered.

3. The complaint and grievance log dated 11/1/18 through 2/10/19 was reviewed on 2/20/19 at approximately 10:30 AM. The log noted on 12/13/18 that Pt#5 called to report a complaint. The complaint summary noted "Pt concern was that nurse was not working with Pt#5 on pain management and did not call physician about pain concerns." Please see A-0119.

4. During an interview on 2/21/19 at approximately 11:30 AM, Vice President of Nursing (E#1) reviewed Pt#5's record and verbally agreed Pt#5's pain was not managed as ordered and should have been. E#1 verbally confirmed Dilaudid should have been administered between 3:15 AM and 3:29 AM for pain assessed at a 6/10. E#1 verbally agreed an order for management of severe pain (7-10) was not obtained and should have been. E#1 verbally agreed the Ibuprofen and Norco were administered outside of the ordered parameters and should not have been

5. During an interview on 2/20/19 at approximately 1:30 PM with the Pharmacist (E#4), E#4 stated, "Dilaudid was an active order." E#4 verbally agreed an order for management of severe pain (7-10) was not obtained and should have been. E#4 verbally agreed the Ibuprofen and Norco were administered outside of the ordered parameters and should not have been.