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Based on medical record review, summary of the hospital's complaint investigation, Call System Report Review, interviews and review of policy and procedure, the Hospital failed to thoroughly investigate Patient Identifier (PI) # 1's complaints voiced to hospital staff on 11/29/17 and failed to follow their own policy regarding grievances. As a result of this deficient practice, PI # 1's concerns were not identified as grievance and/or investigated as a grievance by hospital staff, the root cause of the grievances were not identified, an insufficient number of staff were interviewed, and PI # 1 was not satisfied with the results of the hospital's investigation. This affected PI # 1, one of three sampled patients.

Findings include:

Definition of grievance by Centers for Medicare and Medicaid (CMS):
All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are considered a grievance

1. Medical record review:

PI # 1 is alert and oriented and able to make independent decisions. PI # 1 has multiple diagnoses to include End Stage Renal Disease, Dependence on Renal Dialysis, Insulin-Dependent Diabetes Mellitus, Blindness, Osteoarthritis and Constipation. PI # 1 requires extensive assistance with most activities of daily living.

2. Summary of PI # 1's complaint as reported to Alabaman Department of Public Health (ADPH): PI # 1 was hospitalized 11/23/17 through 12/3/17. Upon PI # 1's return to the facility of residence, the patient reported the following allegations occurred at the hospital:

a. "Neglected and talked down to."

b. Left in urine and bowel movement for hours by hospital staff on more than one occasion. PI # 1 reported this resulted in perineal irritation (redness and swelling).

c. A PCA (Patient Care Assistant) told PI # 1 to pull self up because the PCA wasn't going to break her back pulling on the patient.

b. Hospital staff "spoke down" to PI # 1.

c. Irritation to perineal area as a result of being left soiled.

d. Hospital staff failed to answer PI # 1's call light when patient requested assistance with meal.

e. Call light "purposefully" moved out of PI # 1's reach by hospital staff.

During the entrance conference on 12/19/17 at 10:00 AM, the state surveyors requested a copy of the completed investigation related to PI # 1. A copy of the investigation was provided by the Corporate Quality Director, Employee Identifier (EI) # 1. Staff responded that the copy of the investigation regarding PI # 1 given to the surveyors was complete.

A. The investigation included a single page document titled, "Summary of Patient Complaint Investigation." The report was not dated.

"Below is a case summary of PI # 1 (11/23/17 to 12/3/17) at name of hospital:

We (Hospital) have received an allegation of abuse report from...(name of reporting facility)...the investigation is not final...

Patient (PI # 1) notified EI # 2, Patient Liaison Manager, on 11/29/17 that he/she had been treated rudely. PI # 1 reported he/she was told by a Patient Care Assistant that, "She (PCA) ain't going to break my back pulling and tugging on you to move you up in bed."

PI # 1 reported "ringing the buzzer" for help three different times to get someone to help with his/her meal tray and was told it was right in front of him/her.

Other complaints included:
Being left in a wet diaper all day and the call light was moved out of PI # 1's reach on one occasion.

The team leader and nurse manager investigated the complaint. PI # 1 reported the complaints were limited to the care provided by the PCA.

The Hospital PCA was interviewed and reported the following:

"Patient's tray (PI # 1) was available and the items were opened. However, the patient was blind and did ask for an orientation to the meal tray. Assistance was provided on request. There was one incident when the PCA and nurse moved the call light when providing care and she (PCA) forgot to return the light. She (PCA) denied that it was on purpose." Coaching was provided to the employee (PCA). In regards to the comment about 'breaking my back,' the PCA stated she had just said that she was going to get some help to pull PI # 1 up in bed.

There was no evidence in the medical record or upon staff interview that the patient's (PI # 1) toileting needs were not met."

This document was signed by EI # 1, Corporate Director Quality Management.

B. A copy of an email titled Patient Complaint Notification (hospital based electronic system that including emails) was provided to the surveyors on 12/19/17 at 10:00 AM:

Date Reported: 11/29/17
Date of Event: 11/29/17
Patient Name: PI # 1
Mechanism by which report was received: Patient (PI # 1)
Entered by: Patient Liaison Manager, EI # 2

- The email, dated 11/29/17 at 2:30 PM, was forwarded by EI # 2, Patient Liaison Manager, to EI # 3, Acting Nurse Director, of the unit where PI # 1 was hospitalized:

"The patient (PI # 1) called to complain that he/she was treated rudely while here this time. PI # 1 is blind and has to have help with everything and yet was told by her PCA, "She ain't going to break her (PCA) back pulling and tugging on PI # 1 to move the PI # 1 up in the bed." PI # 1 said that he/she rang the buzzer for help three different times to get someone to come help get him/her ready for him/her to eat and the PCA said, 'Your tray is right in front of you.' (PI # 1) answered, "I'm blind, I need help getting the tops off things and telling me where different things are located on the tray.

(PI # 1) said he/she lay in a wet diaper all day last week and got a terrible yeast infection from that. It is a real problem getting help on and off a bedpan. PI #1 pushed the buzzer so many times that the PCA came in the room and moved it to the bedside table where PI # 1 could not reach it so PI # 1 would stop buzzing them for help... I told PI # 1 would write up his/her concerns and send them to the Nurse Manager..." (documented by EI # 2, Patient Liaison Manager).

- Email dated 11/30/17 at 7:34 AM and sent by EI # 3, Nurse Manager of the Unit where PI # 1 was located in the hospital, to the Nurse Manager / Clinical Resource Team, EI # 5, (Manager of PCA accused of mistreatment by PI # 1):

" First name of PCA (Patient Care Assistant) in Clinical Resource Team, was assigned to this patient (PI # 1) today. I spoke with the patient and her only complaint was regarding the the comments and care received today."

(There was no additional documentation by the Unit Nurse Manager, EI # 3, of her conversation with the PCA identified by PI # 1.)

Brief Description of Complaint by EI # 5, Nurse Manager / Clinical Resource Team:

"I talked with (name of PCA assigned to PI # 1) and had her explain to me what had taken place today... When asked about the meal tray incident, the PCA, told me that Dietary was in PI # 1's room setting up PI # 1's tray when she (PCA) heard the patient (PI #1) talking loudly and upset. The PCA went in the room to see if PI # 1 needed any help with his/her tray and the patient (PI # 1) told her he/she was blind and needed help opening lids and told where the food was. PCA told PI # 1 that the lids were already open and she showed her where everything was so PI # 1 could feed his/herself...

I then asked about the incident about the call light taken away from PI # 1 so he/she could not call. (First name of PCA) stated this was not true. PCA told me that she and another nurse (from Dialysis) went to PI # 1's room to reposition PI # 1 in bed. The PCA said that they moved the phone and the call light off the bed and placed it on PI # 1's bedside table so it would not get tangled up when they repositioned PI # 1. Once they were finished repositioning PI # 1 they forgot to place the phone and the call light back in PI # 1's bed. The PCA then stated that once she remembered, shortly after, she returned to the room and placed the phone and the call light back in on PI # 1's bed.

I finally asked her (PCA) about the comment 'she ain't going to break her back pulling and tugging on PI # 1 to move her up in bed.' The PCA denied making this comment and told me that she only told the patient (PI # 1) that she was going to get some help when PI # 1 asked to be pulled up in bed or repositioned. She (PCA) then stated that she also had someone assist her with PI # 1's bath as well."

(There was no documentation by hospital staff of interview with employee who assisted PCA with PI # 1's bath as of 12/2917 at 10:00 AM).

...the PCA said she did not forget to place the call light or phone back in PI # 1's bed on purpose."

II. Interviews:

1. Employee Identifier (EI) # 4, Patient Care Assistant:

An interview was conducted on 12/19/17 at 12:10 PM with EI # 4 who stated he/she remembered providing care for PI # 1 on 11/29/17. EI # 4 stated that he/she works in the float pool for the hospital and had not been assigned to the 4 South unit in about 3 or 4 months. EI # 4 also stated she had not previously taken care of PI # 1 before 11/29/17.

EI # 4 revealed that on 11/29/17, he/she was approached by EI # 6, Dialysis RN, who requested help to pull PI # 1 up in bed. EI # 4 stated she and EI # 6, pulled PI # 1 up in bed. Prior to pulling PI # 1 up, the call light and the phone were placed on the table next to the bed.

EI # 4 stated after pulling PI # 1 up in the bed, he/she stated angrily,"You took too long." PI # 1 stated he/she had been calling for help with his/her breakfast tray all morning, to which EI # 4 stated she told PI # 1, "It's in front of you." EI # 4 stated PI # 1 then replied, "I'm blind." The surveyor asked EI # 4 if she was aware that PI # 1 was blind and he/she replied, "No, I was only told he/she was a 'complete' (requires total assistance with Activities of Daily Living (ADLs): eating, toileting,etc.) during shift report," by the offgoing 7 PM to 57AM PCA.

EI # 4 stated after being told by the patient (PI # 1) that he/she was blind, she assisted the PI # 1 by opening the containers on the tray. The surveyor asked EI # 4 if she oriented PI # 1 to his/her tray, informing PI # 1 where the hot and cold items were located, informing what was in each container, to which EI # 4 stated she did not do that for the patient.

After setting up the breakfast tray, EI # 4 stated she and EI # 6/ Dialysis Registered Nurse (RN) left the room and failed to place the call light in safe reach of PI # 1 prior to exiting the room. EI # 4 stated this was a mistake and not done on purpose.

2. Interim Nurse Manager 4 South / EI # 3

During an interview on 12/19/17 at 1:50 PM, EI # 3 stated she received an email from the Patient Liaison Manager about PI # 1's concerns on 11/29/17 and she went to check on the patient. EI # 3 informed PI # 1 that she was there to ask about PI # 1's concerns relating to pain medication and of not being changed (left soiled). Because PI # 1's barely opened her eyes, EI # 3 said she would return for a follow up visit. EI # 3 identified the PCA who was assigned to care for PI # 1. The next day, EI # 3 visited PI # 1 and the patient voiced no concerns. Because the PCA assigned to PI # 1 was part of the Clinical Resource Team (CRT), EI # 3 forward the email from the Patient Liaison Manager to the CRT Nurse Manager about PI # 1's concerns.

Although EI # 3 is the Interim Nurse Manager for the unit where PI # 1's room was located, she did not address PI # 1's concerns with the PCA (EI # 4) assigned to the patient. When asked if she documented her discussion with PI # 1, EI # 3 replied, "no."

3. EI # 5, Nurse Manager Clinical Resource Team (also known at Float Pool) and
PI # 1's Manager

EI # 5 stated he talked with EI # 4, PCA assigned to PI # 1 on 11/29/17, and the PCA said another Float Pool PCA helped her bathe PI # 1. EI # 5 stated he talked with the assisting PCA, but there was no documentation of any conversation / interview with the PCA. EI # 5 also stated he was aware of the involvement of the Dialysis RN in the incident, but there was no documentation of an interview in the hospital's investigation. EI # 5 said, " I didn't know where to take the lead."

4. Dialysis RN / EI # 6

During an interview on 12/19/17 at 2:45 PM, EI # 4 stated she went to PI # 1's room to get PI # 1 for dialysis treatment on 11/19/17 sometime around 7:30 AM, but PI # 1 said, "no, because he/she was not ready." PI # 1 stated he/she had called 2 - 3 times for help with meal set up and to be pulled up in the bed, but had not been assisted by staff.

EI # 6 said she went for help because she could not move PI # 1 without assistance. According to EI # 6, she saw EI # 4 ( PCA assigned to PI # 1) coming out of a patient room and, "We (RN and PCA) pulled the patient up in bed." PI # 1 requested help with his/her breakfast tray because staff had not come to assist him/her. We set the tray in front of the patient (PI # 1) and both of us took the tops off of the food, but did not tell PI # 1 patient what was on the tray.

EI # 6 stated PI # 1's call light and phone were placed on the table when PI # 1 was repositioned. EI # 6 also knew PI # 1 was blind because she previously provided care to the patient. EI # 6 stated she and the PCA (EI # 4) both failed to give PI # 1 the call light back prior to leaving the room, but it was not on purpose.

5. EI # 8, 4 South RN assigned to PI # 1 on 11/29/17

An interview was conducted on 12/20/17 at 10:03 AM with EI # 8 who stated he/she was aware that PI # 1 was blind and he/she did not convey this to EI # 4 (PCA) during shift report on 11/29/17. EI # 8 stated he/she was assigned to PI # 1 on 11/29/17 and upon entering the room, PI # 1 complained that EI # 4 had not assisted her with his/her tray, that he/she had called the desk 3 times that morning and no one answered, and that on one instance, his/ her call light was purposefully left out of reach by EI # 4.

EI # 8 stated she then spoke with EI # 4 about the complaints of PI # 1 and informed EI # 4 that PI # 1 was blind, and EI # 4 responded "I didn't know." EI # 4 then informed EI # 8 that the Dialysis RN (EI # 6) was also present in the room during the incident in question and they both failed to replace the call light in reach of PI # 1 after they provided care. EI # 8 reported the complaints to the unit Team Leader.
(There was no documentation by the Team Leader in the hospital's investigation.)

6. EI # 9, Chief Medical Officer

During an interview on 12/20/17 at 9:45, EI # 9, stated the investigation is ongoing. EI # 9 identified the single page document presented to the surveyors on 1/19/17 as "preliminary report, a way to validate the allegation" from the reporting facility. (The date the hospital was notified after PI # 1's discharge by the reporting facility of an "Allegation of Neglect" was 12/4/17 based on the document provided by the reporting facility to ADPH).

EI # 9 was asked if the hospital categorized PI # 1's concerns as reported by the patient on 11/29/17 as a grievance or a complaint. EI # 9 replied grievances and complaints are treated the same. We (hospital) don't differentiate between grievance and complaints."

7. PI # 1

During a telephone interview on 12/20/17 at 11:30 AM, PI # 1 was asked about hospital staff follow up after he/she voiced concerns while hospitalized on 11/29/17. PI # 1 said, "Nothing happened. I wanted them to take better care of me." When asked how he/she felt when staff allegedly talked "rudely" to him/her PI # 1 said, "Like a second class person. Not worth anything." PI # 1 was asked if he/she was able to call for staff assistance when left soiled. PI # 1 replied, I called and I called and called again. The person at the desk answered, but nobody came in the room." PI # 1 was asked if his/her concerns were satisfactorily resolved by the hospital. PI # 1 replied, "No."

III. Call System Report Review:
The Surveyors were provided with the Call System report for PI # 1 in which 285 calls were made from PI # 1's room from 11/23/17 - 12/3/17. The Surveyor noted on 11/29/17, PI # 1 patient activated the call light system six times from 6:00 AM to 8:00 AM. There was no sensor report to validate if a staff member entered PI # 1's room after the call was received at the desk.

IV. "Customer Grievances Policies and Procedures I.G. 23": Provided to surveyors by Employee Indentifer (EI) # 9, Chief Medical Officer, on 12/20/17 review includes:

Purpose: To provide a consistent, effective and efficient mechanism by which customer/patient grievances are managed, resolved and responded to as required by the Centers for Medicare and Medicaid Conditions of Participation (COP's).

Summary of the Regulation:
Require that a hospital:
- establish a process for for the prompt resolution of patient grievances;
- Deal with relatively minor complaints (bedding, food quality, etc.) in a timely manner and
- Provide a written response to more significant issues, defined as grievances.

Grievances include a written or verbal complaint that is made to the hospital by a patient or a patient's representative regarding:
- the patient's care...
- neglect or abuse...

Grievances must be responded to by the hospital within 7 business days. If a longer time is required to resolve the grievance, an initial written communication will be provided within 7 days and a final resolution will be reported in writing, in 30 days except in extreme circumstances.

... II. Purpose:
To ensure all complaints and grievances...are handled in a manner to foster satisfactory resolution in a timely manner...

III. Patient Grievance: ... A written or verbal complaint that is made to the hospital by a patient or the patient's representative regarding the patient's care, abuse or neglect...

... All verbal or written complaints regarding abuse, neglect, patient harm...are grievances.

A verbal complaint is a grievance if:
- It cannot be resolved promptly, on the spot, by staff present;....
- It requires investigation;
- It is referred to other staff for later resolution;
- Requires further actions for resolution...

V. Responsible Persons...
All hospital employees are responsible for responding to patient complaints or
grievances in a timely manner...

VII. Procedure
a. In the case of a grievance, the appropriate contact from Administration, Patient Representative, or Marketing will coordinate with Managers/Directors to investigate and to formulate a resolution to the grievance within calendar four days.

As of 12/19/17, 20 days after the hospital was aware of PI # 1's grievance, hospital staff had only interviewed the PCA assigned to PI # 1. The state surveyors began on onsite investigation on 12/19/17 and the hospital subsequently began investigating the employees identified by the surveyors as significant to the investigation. Additionally, the hospital failed to resolve PI # 1's grievances within four days based on their own policy.

Based on review of facility policy, Daily Roster, Call Systems Report Critical Alert Call Details Report and interviews with staff and patient interviews with PI (Patient Identifier) # 1 and # 3, it was determined the hospital failed to ensure the patients on the 4 South Unit (4 South) (Dialysis Unit) were in a safe environment by:

1. Ensuring the call light was in safe reach of the patients at all times.

2. Conducting detailed off-going shift report between PCAs (Patient Care Assistants) and RNs (Registered Nurses)

3. Orienting a visually impaired patient to his/her environment.

4. Timely answering the call light signal to meet patient needs.


This affected 2 of 5 patients interviewed including Patient Identifier (PI) # 1 and # 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Lippincott Procedures - Service Excellence
Revised: August 12, 2016

"Introduction: Every patient who enters a health care facility expects high-quality care and services....
Essential components of service excellence includes maintaining open communication with patients and their families, being responsive to their needs and expectations, and providing immediate service recovery when service failures occur....

Implementation: Explain to the patient how he can contact you when necessary - for instance, by using the call light or calling a designated phone number....
Ensure that the patient's personal items, such as a water container, tissues, the trash container, the television remote control, and the call light, are within easy reach.
Before leaving the room, ask the patient and his family if they need anything else. Be prepared to meet those needs and solve problems, as needed. Remind the patient how to contact you.

Special Considerations:
Ensure a smooth transition of care between health care providers; include the patient in handoff communication whenever possible.
Conduct hourly patient rounds to ensure that each patient's needs and service expectations are met and to maintain patient safety....
Possessions- Assess the patient's environment to make sure he can easily reach personal items, such as the call light...."

A. PI # 1 Complaintant

PI # 1 was admitted to the facility on 4 South on 11/23/17 with diagnoses including Renal Failure and Fluid Overload. PI # 1 was blind with documentation on the 11/23/17 admission narrative that he/she can only see shadows. PI # 1 initiated a telephone complaint on 11/29/17 to EI # 2, Patient Liaison Manager, in which he/she alleged the staff failed to:

a. Placed his/her call light in safe reach on 1 occasion
b. Answer his/her call light after he/she pushed it 3 different times attempting to get assistance with the breakfast meal tray.
c. Take into consideration the patient being blind and did not assist him/her by setting up the breakfast tray, but told the PI # 1,"its right in front of you".

B. Review of Daily Roster by Unit

The surveyor reviewed the Daily Roster by Unit for the 7 PM to 57AM shift on 11/28/17 to 11/2917 and the 57AM to 3 PM shift on 11/29/17 to identify staff that cared for PI # 1.
The Patient Care Assistant (PCA) assigned to PI # 1 on the 7 PM to 7 AM shift, a 4 South PCA.
The PCA assigned to PI # 1 on the 57AM to 3 PM shift was Employee Identifier (EI) # 4, PCA from the CRT (Clinical Resource Team) (float pool). The RN (Registered Nurse) assigned to PI # 1 on the 57AM to 3 PM shift was EI # 7, a 4 South RN.

C. Staff Interviews

1. EI # 2, Patient Liaison Manager

An interview was conducted on 12/19/17 at 3:50 PM with EI # 9 who stated on 11/29/17, he/she received a call was from PI # 1, a 4 South patient, with allegations including being talked to rudely by a staff member when he/she asked to be pulled up in bed, the staff member replied he/she was not going to break their back pulling and tugging on the patient; that he/she had to ring the call bell 3 times to get assistance with meal tray; on one occasion, the call light was purposefully put out of his/her reach; and on an unspecified date, he/she was allowed to lie in soiled diaper all day, resulting in a yeast infection.

EI # 2 stated per agency policy, after speaking with the patient on the phone, he/she entered the complaint information into MIDAS (Medical Information Data Analysis System) and sent an email and made a phone call to the Interim Nurse Manager for 4 South, EI # 3, to alert him/her of the complaint.

2. EI # 4, PCA, CRT

An interview was conducted on 12/19/17 at 12:10 PM with EI # 4 who stated he/she remembered providing care for PI # 1 on 11/29/17. EI # 4 stated that he/she works in the float pool for the hospital and had not been assigned to the 4 South unit in about 3 or 4 months. EI # 4 also stated he/she had not previously taken care of PI # 1 before 11/29/17.

EI # 4 revealed that on 11/29/17, he/she was approached by EI # 6, Dialysis RN, who requested help to pull PI # 1 up in bed. EI # 4 stated he/she and EI # 6, pulled PI # 1 up in bed. Prior to pulling PI # 1 up, the call light and the phone were placed on the table next to the bed.

EI # 4 stated after pulling PI # 1 up in the bed, he/she stated angrily,"you took too long". PI # 4 stated he/she had been calling for help with his/her breakfast tray all morning, to which EI # 4 stated he/she told him/her, "it's in front of you." EI # 4 stated PI # 1 then replied, "I'm blind." The surveyor asked EI # 4 if he/she was aware that PI # 1 was blind and he/she replied, "No, I was only told he/she was a complete (requires total assistance with ADLs), during shift report" by the 7 PM to 57AM 4 South PCA.

EI # 4 stated after being told by the patient that he/she was blind, he/she assisted the patient by opening the containers on the tray. The surveyor asked EI # 4 if he/she oriented the PI # 1 to his/her tray, informing where the hot and cold items were located, informing what was in each container, to which EI # 4 stated he/she did not do that.

After setting up the breakfast tray, EI # 4 stated both EI # 4 and EI # 6 left the room and failed to place the call light in safe reach of PI # 1 prior to exiting the room. EI # 4 stated this was a mistake and not done on purpose.

The surveyor inquired about off-going shift report and EI # 4 stated he/she received shift report from the 7 PM to 57AM PCA, and was not informed that the patient was blind. EI # 4 stated during off-going shift report, the off-going PCA only tells if the patient is an "assist" (requires partial assistance with activities of daily living, ADLS) or a "complete." EI # 4 stated the Kardex (care summary report) did not state the patient was blind. The surveyor asked EI # 4 if the RN assigned to the patient, EI # 7, gave him/her a report prior to the patient encounter on 11/29/17, and he/she stated "no, they usually don't, unless its something special that the patient needs on my shift. The surveyors attempted to contact the 7 PM to 57AM 4 South PCA by phone but was unsuccessful. The facility's Director of Patient Care services stated he/she was also unsuccessful in contacting the 7 PM to 57AM 4 South PCS for an interview.

3. EI # 6, Dialysis RN

An interview was conducted on 12/19/17 at 2:45 PM with EI # 6 who stated he/she went to the room of PI # 1 on 11/29/17 to take him/her to Dialysis. PI # 1 asked to be pulled up in the bed. EI # 6 went to get help and asked EI # 4 to assist him/her to pull the patient up in the bed. EI # 6 stated the call light and phone were placed on the table and PI # 1 was pulled up in bed. EI # 6 then stated, PI # 1 requested help with his/her breakfast tray and that no one had come to assist him/her. Both EI # 4 and EI # 6 took the tops off of the containers of the breakfast but did not tell the patient what was on the tray. EI # 6 was aware PI # 1 was blind due to having cared before for the patient. EI # 6 stated they both failed to give PI # 1 the call light back prior to leaving the room, but not on purpose.

EI # 6 stated PI # 1 refused to go to Dialysis at that time. EI # 6 stated he/she informed EI #7, the 4 South RN assigned to PI # 1, about the refusal and then passed PI # 1's room, he/she overheard PI # 1 on the phone with someone, complaining about the care received.

4. EI # 8, 4 South RN assigned to PI # 1 on 11/29/17

An interview was conducted on 12/20/17 at 10:03 AM with EI # 8 who stated he/she was aware that PI # 1 was blind and he/she did not convey this to EI # 4 (PCA) during shift report on 11/29/17. EI # 8 stated he/she was assigned to PI # 1 on 11/29/17 and upon entering the room, PI # 1 complained that EI # 4 had not assisted her with his/her tray, that he/she had called the desk 3 times that morning and no one answered, and that on one instance, her call light was purposefully left out of her reach by EI # 4.

EI # 8 stated she then spoke with EI # 4 about the complaints of PI # 1 and informed EI # 4 that PI # 1 was blind, and EI # 4 responded "I didn't know". EI # 4 then informed EI # 8 that the Dialysis RN (EI # 6) was also present in the room during the incident in question and they both failed to replace the call light in reach of PI # 1 after they provided care. EI # 8 reported the complaints to the unit Team Leader.

EI # 8 continued to say that two Dialysis PCA's came back within an hour to get PI # 1 for dialysis and he/she informed them of his/her complaints. The two Dialysis PCA's went back and reported the complaints to EI # 6. EI # 8 said EI # 6 called him/her and stated EI # 4 had not been rude to EI # 4 and that he/she was present in the room with EI # 4 and had assisted EI # 4 with setting up the meal tray for PI # 1 after they pulled him/her up in bed.

Surveyor asked EI # 8 if it was routine for the PCA to get off-going shift report from the RN. She responded no, the RN would tell the PCA if there was something specific to that patient that needed to be done during their shift but normally the PCA gets report from another PCA from the previous shift.

5. EI # 1, Quality Assurance Director
An interview was conducted on 12/19/17 at 10:30 AM with EI # 1 regarding the complaint investigation that he/she conducted related to PI # 1 alleging the call light was placed out of his/her reach on one occasion purposefully. EI # 1 stated and he/she conducted an interview with EI # 4 and confirmed the call light was not placed in easy reach of PI # 1 after care was completed on 11/29/17.

During the interview on 12/19/17 at 10:30 AM, the surveyors requested the sensor report which is used to show that staff are making safety rounds and responding timely to call lights throughout the facility which would include PI # 1's room and was told by EI # 1 the sensor report system was not working currently and was not working during this reported complaint on 11/29/17. Surveyors asked EI # 1 if the facility had a back up plan in place to ensure staff answering patients call lights timely while the system being down, EI # 1 stated there was no other backup process initiated.

Surveyors were provided with the Call System report for PI # 1 in which 285 calls were made from PI # 1's room from 11/23/17 to 12/3/17. The Surveyor noted on 12/19/17, the patient activated the call light system 6 times from 6:00 AM to 8:00 AM. There was no sensor report to validate if a staff member went into the patient's room after the call was deactivated at the desk during these times.

6. EI # 3, Interim Nurse Manager for 4 South
An interview was conducted on 12/19/17 at 2:00 PM who stated after receiving the email through MIDAS, he/she went to the room of PI # 1. EI # 3 was told by PI # 1 that the call light was placed out of his/her reach by EI # 4. PI # 1 also told EI # 3 that EI # 4 spoke rudely to him/her after he/she request to be pulled up in the bed, and stated on an unspecified day, he/she was left in a soiled diaper.

EI # 3 did not speak with EI # 4 for clarification, but contacted EI # 4's supervisor about the complaints because EI # 4 was from the float pool. EI # 3 stated on 11/30/17 when he/she made rounds on 4 South, PI # 1 voiced no complaints so she though everything was resolved. EI # 3 did not provide written documentation of the aforementioned events.

7. PI # 1 telephone interview
Surveyors called PI # 1 and spoke with her on the telephone on 12/20/17 at 11:30 AM. PI # 1 stated that during his/her hospitalization beginning 11/23/17, he/she would push the call bell , then someone would answer it at the nurses station, but no staff member would come into the room, so he/she would call back multiple times. PI # 1 stated this practice of no one coming to assist him/her happened again when he/she got his/her breakfast tray on the morning of 11/29/17. PI # 1 stated he/she pushed the call bell 3 times and no one came to help him/her with breakfast.

D. Review of the Critical Alert Call Details Report
Surveyor review of the facility's Critical Alert Call Details Report for room 422, Bed 1(PI # 1's bed number) revealed PI # 1 activated the call system on 11/29/17 a total of 34 times. Between 6:00 AM and 8:00 AM, PI # 1 activated the call system at the following times:
6:40 AM
7:05 AM
7:12 AM
7:23 AM
7:28 AM
7:38 AM
PI # 1 activated the call light system a total of 285 times from admission on 11/23/17 to discharge on 12/3/17.

The surveyors requested a copy of the facility's Sensor report to make a comparison of when the call was deactivated at the desk and when a staff member actually entered into the patients room, but were told by EI # 1, the system was broken and no report could be run for the time PI # 1 was in the facility from 11/23/17 to 12/3/17.

E. PI # 3 Complaint
PI # 3 was admitted to the facility on 4 South on 12/09/17 with diagnoses including Generalized Weakness, Diarrhea and Fever.

On 12/19/17 at 10:40 AM, the surveyors toured the 4 South Unit. PI # 3 was interviewed in room 429. During the interview, the surveyors inquired about how staff on all shifts responded to the call light system during this admission. PI # 3 stated a few nights ago, on the night shift, he/she woke up during the night and realized his/her call light was not in reach. PI # 3 stated it was for at least 3 hours. The surveyor asked if any staff made rounds in the room during the 3 hours, PI # 3 stated he/she did not see anyone come in his/her room. The surveyors asked how he/she got the call light back, PI # 3 stated he/she had to slide down in the bed to get it off of the floor.

Based on medical record (MR) review and interviews with the WOCN (Wound Ostomy and Continence Nurse) of the hospital and Employee Identifier (EI) # 4, PCA (Patient Care Assistant), it was determined the facility failed to ensure:

1. The Registered Nurse (RN) accurately assessed and documented the skin condition of a patient with reported perineal skin irritation.


2. Appropriate consults were made by the RN staff to the WOCN for wound care treatment recommendations.


3. The RN documented information on the admission assessment correctly to generate the Kardex (care summary report) for other staff caring for the patient.


This affected 1 of 3 charts reviewed including Patient Identifier (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

A. PI # 1 was admitted on 11/23/17 with diagnoses including Renal Failure and Fluid Overload.

Review of the 11/23/17 RN Adult Admission assessment

The Initial RN Adult Admission assessment was performed on 11/23/17 revealed documentation that the skin of PI # 1 is intact, with gross edema, generalized and no rash.

Further review of RN system assessments dated 11/24/17, 11/25/17, 11/26/17, 11/29/17 and 11/30/17 continue to document skin is intact, with gross edema, generalized and no rash.

Review of the Medical Record of PI # 1

Review of the Medical record of PI # 1 revealed an order on 12/1/17 by the hospitalist (hospital staff physician) and documentation that "patient reported vaginal candidiasis" and Diflucan (an antifungal medication) was ordered for yeast infection.

Upon further review of the MR with EI # 11, Information Technology (IT) staff, assisting with navigation in the EMR (electronic medical record), it was noted on the 11/23/17 RN Adult Admission Assessment the RN documented PI # 1 had "Normal Vision" and on the assessment where "Blind" was located, the section was blank. The surveyor asked EI # 11 if the aforementioned sections populate the Kardex, EI # 11 replied "Yes". The surveyor later asked if the narrative note that the nurse typed at the end of the admission assessment populate the Kardex, EI # 11 replied "No." The surveyor asked EI # 11 if he/she could print the Kardex that would have been used for PI # 1's hospital stay for 11/23/17 to 12/3/17, EI # 11 replied "No".

On 12/4/17 a grievance was initiated by the SNF (Skilled Nursing Facility) where PI # 1 resides, alleging the patient sustained irritation to the vaginal area related to patient being allowed to lie in soiled diapers for hours on more than one occasion.

The SNF conducted an Initial Body Audit upon PI # 1's return from the hospital stay and noted right labia swelling, reddened right labia that PI # 1 stated was due to being left in BM (bowel movement) for hours at the hospital.

B. Staff interviews

1. EI # 4, Patient Care Assistant
An interview was conducted with EI # 4 on 12/19/17 at 12:10 PM who revealed that on 11/29/17, PI # 1's perineal area was "raw, red and swollen" and an ointment provided by the facility, which was at the bedside and used by EI # 4 on 11/29/17 after completing the bathing of the perineal area.

2. EI # 10, WOCN
On 12/2017 and interview was conducted with EI # 10 who stated he/she was asked by EI # 1 to review the medical record for appropriate care regarding skin/wound care.

EI # 10 stated there was no documentation by the nursing staff that PI # 1 had any skin irritations. EI # 10 stated when a patient is admitted with pressure ulcers or skin irritations that require complex care, the wound nurse is consulted and the facility RNs have a High Risk Order Set that has been established and signed off on by the medical staff for the facility to use. When asked if the consult or if the Order set was initiated for PI # 1, EI # 10 stated "No" and confirmed the above findings related to the skin irritation.

The surveyor asked EI # 10 what type of cream would have been at the bedside for PI # 1 since there was no documentation of any cream ordered. EI # 10 stated the cream that is located in the Par Level (supply room) is Cardinal Manuka Barrier Cream and can be used without a physicians order. The surveyor asked if the use of this cream should be documented by the RNs performing system assessments, EI # 10 replied "Yes, and it should be on the Kardex." The surveyor asked if during the chart review that was conducted by EI # 10, if any documentation was found, EI # 10 replied, "No."

Based on direct observations it was determined the facility failed to ensure the PCA (Patient Care Assistant) on 4 South performed proper infection control when filling the patient's bedside ice pitcher. This affected 1 of 4 patients interviewed including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

1. PI # 3 was admitted to the facility on 4 South on 12/09/17 with diagnoses including Generalized weakness, Diarrhea and Fever. PI # 3 stated he/she has a diagnosis of Lung Cancer.

During the tour of 4 South on 11/19/17 at 11:02 AM, the surveyors were in the room of PI # 3. The surveyors were in the room interviewing PI # 3 when a 4 South PCA entered the room carrying a plastic ziplock bag filled with ice. As the 4 South PCA approached the bedside table with the bag of ice, the surveyors observe him/her drop the bag of ice on the floor. The surveyors observed 4 South PCA pick the bag of ice up from the floor, and placed approximately half of the now dirty ice in the pitcher of PI #3 and immediately left the room with the rest of the partially filled bag of ice.

The surveyors did not observe 4 South PCA perform hand hygiene when entering the room or after completion of filling of the ice pitcher.