HospitalInspections.org

Based on review of hospital policy, grievance documentation, and staff interview, it was determined the hospital failed to inform complainants of the timeframe for provision of a response to grievances for 4 of 4 grievances (A, C, D, E) whose grievances required greater than 7 days to investigate and respond. This resulted in a lack of clarity as to when patients could expect to hear responses to their grievances. Findings include:

A hospital policy, "Patient Complaint and Grievance Program -- SAHS," approved 6/06/19, addressed a timeframe to resolve grievances. It stated "If the grievance...cannot be resolved within 7 calendar days, PR [Patient Relations] will notify the patient or patient's representative via an extension letter of the need for additional time and the expected timeframe for resolution. The [title] will strive to resolve all grievances within 30 calendar days of receipt of the grievance."

Grievance documentation was reviewed for grievances A, C, D, and E. All grievance files included copies of letters sent to the complainants to acknowledge receipts of their complaints. Each letter stated, "Upon completion of our review, we will contact you by letter to inform you of the outcome, within a reasonable time frame."

The letters did not specify an anticipated time frame for review and the provision of a response.

The Regional Manager of Patient Relations was interviewed on 3/03/20 at 11:35 AM. She stated, based on a consultant's recommendation, the hospital recently made a change to remove the dates from the acknowledgement letters and instead referenced within a "reasonable time frame." She acknowledged the letters did not specify dates to expect resolution letters. She stated it was their process to respond within 30 days.

Complainants A, C, D, and E were not informed of time frames for review of grievances and provisions of responses.

Based on staff interview and review of hospital policy, patient rights brochure, and medical record review, it was determined patients were not kept informed of health status and involved in care planning and decision making for 1 of 6 patients (Patient #2) whose medical records were reviewed. This resulted in a lack of patient education and collaboration for decision-making. Findings include:

A hospital policy, "Patient Rights and Responsibilities -- SAHS," approved 6/12/19, stated "SAHS promotes and supports the rights of each patient:.. to receive information in a manner he or she understands...To make informed decisions regarding his or her care:
a. To receive complete information about their illness and state of health.
b. To participate in their plan of care, discussing and working together with their physician to make decisions regarding their treatment.
c. To request or refuse treatment to the extent permitted by law.
d. To have their pain assessed and to be involved in decisions about treating their pain."

A hospital policy, "Plan for Provision of Care," approved 12/13/19, stated "Each patient who received care at SARMC can expect care as outlined in the Patient Rights Brochure." The undated hospital brochure, "Patient Rights & Responsibilities," stated "you have the right to make informed decisions regarding your care, including the rights to...Receive complete information about your diagnosis and state of health".... and "have your pain assessed and to be involved in decisions about pain management."

A Telemetry RN was interviewed on 3/03/20 at 9:00 AM. When asked how nursing staff included patients in their plans of care, she stated patients were included through education, discussing plans and procedures, answering questions, and including them in decision-making.

A second Telemetry RN was interviewed on 3/03/20 at 9:10 AM. When asked how nursing staff included patients in their plans of care, she stated, they discussed and educated them on their plans of care, answered questions, and kept them updated on what to expect.

A hospital policy, "Charting Guidelines, Telemetry Inpatient and Post-Procedure Outpatient," approved 8/23/19, stated:

"Education documentation
1. Patient education is documented on admission and at least once per shift. Include patient's/family's response in the evaluation.
2. Document any barriers to teaching.
3. Document in detail education that has been provided. This includes what has been discussed, handout provided, videos, classes attended, and shows on TV [television].
4. Include patient's/family's response in the evaluation."

Hospital policies and rights information were not followed. Examples include:

Patient #2 was a 52 year old female who arrived in the ED on 2/12/20 for evaluation after a motor vehicle accident. She was subsequently admitted to Telemetry for observation of a low heart rate, that occurred after administration of medication in the ED setting, and prior to a planned discharge to home. She was discharged on 2/14/20.

1. There was no documentation Patient #2 was included in her plan of care as it related to the addition of new medications after admission, such as insulin. There was no documentation of diabetic education as it related to newly prescribed insulin.

2. There was documentation Patient #2 underwent, per physician's orders, multiple tests, including electrocardiogram, echocardiogram, multiple blood tests, a urine drug screen, a urinalysis, a nasal screen for MRSA, and CT scans. Although an ED physician's note, dated 2/12/20, documented discussing with Patient #2 the results of a CT scan, there was no documentation in the ED record or inpatient record that described professional staff communicating other test results to Patient #2 and ongoing health status.

3. There was no documentation Patient #2 was included in her plan of care as it related to a pain management plan, new or omitted medications related to pain or diabetes. There were provider orders for pain medication but no coordinated or developed plan for pain management.

a. There was no documented ED RN pain assessment of Patient #2, upon arrival 2/12/20 at 3:15 PM. An ED RN pain assessment at 2/12/20 at 4:49 PM documented a pain level of 8 on a scale of 1-10, over an hour and a half after arrival in the ED. An ED RN documented administering pain medication, per physician orders, as follows: morphine 2 mg IV push for pain at 2/12/20 at 4:49 PM, oral ibuprofen and oral Flexeril 5 mg at 2/12/20 at 4:57 PM, and a lidocaine topical patch at 4:59 PM. After administration of medications, when Patient #2 was getting ready to be discharged home, she developed an episode of lightheadedness with bradycardia, and was admitted to Telemetry for observation of her low heart rate. There was no documentation staff discussed pain management options with Patient #2 prior to or after administration of medications.

b. An admitting History & Physical report, dated 2/12/20, dictated 2/13/20 at 12:23 AM, signed by a physician assistant and co-signed by a physician, documented a plan to hold Patient #2's metformin, which she was taking prior to admission, and to hold any sedating medications and to limit pain medication to NSAIDs and Tylenol, and to discontinue lidocaine patches and Flexeril. There was no documentation staff discussed medication changes with Patient #2, at the time or later.

c. A physician's progress note, dated 2/13/20 at 1:55 PM, documented "Would like to avoid any narcotics or Imitrex at this time due to possible exacerbation of bradycardia." There was no documentation Patient #2 was informed of this decision, the reasoning behind the decision, and able to participate in a pain plan for her migraine headaches or pain related to injuries from the MVA.

d. A nursing progress note, dated 2/14/20 at 1:42 PM, documented Patient #2's discharge medications did not include any narcotics. When Patient #2 expressed upset about not being prescribed narcotic medication she was on prior to admission, there was no documentation the physician's reasons for omitting narcotics were explained to her.

Documentation stated: "Nursing Progress Note: Patient began to get upset during discharge when she saw there was only ibuprophen [sic] prescribed. I told the patient I would contact the doctor via doc halo and find out if she could have something else for pain but I also reminded the patient about our previous discussion this am and that the doctor had said this morning already that she was not going to prescribe any narcotic for discharge. The doctor replied through doc halo and said again no narcotics, that she prescribed ibuprophen [sic], tylenol [sic] and a lidocaine patch... I Doc Haloed the doctor again, the answer was the same, she said the patient could call her primary doctor, but she was not going to give her narcotics. The patient said, im [sic] not leaving, call my cardiologist [name] on the phone. he said this am that I could have some Tylenol 3, he said codine [sic] would not be bad for my heart and that was going to order it. I called the NP for cardiology, she said that Dr [name] had said yesterday that she could while an inpatient at the hospital have codien [sic] and at no time had they told her would prescribe it."

There was no documentation Patient #2 was informed by a provider the reason Patient #2 could not be prescribed a narcotic medication she was taking prior to her admission. She was not given the opportunity to discuss her questions and concerns with a provider prior to discharge.

The Director of Acute Care was interviewed on 3/03/20 between 8:15 AM and 9:30 AM. She reviewed Patient #2's medical record. She confirmed there was no documentation Patient #2 was educated on the newly prescribed insulin while an inpatient. There was no documentation staff discussed test results with Patient #2, except CT results discussed in the ED. She confirmed physicians had documented reasons for withholding medications but did not document informing Patient #2 of the reasons.

Patient #2 was not kept informed of her health status and test results and was not kept current on medical decision making as it related to medication treatment of pain and diabetes.

Based on policy review, medical record review, grievance documentation, and staff interview, it was determined the hospital failed to ensure patients were given access to their current medical records upon oral request for 1 of 1 patient (Patient #2) who requested access to medical records and whose medical records were reviewed. This frustrated legitimate effort of an individual to access current medical records and resulted in a delay in accessing medical records until after hospitalization. Findings include:

A hospital policy, "Patient Rights and Responsibilities -- SAHS," approved 6/12/19, was reviewed. It stated "SAHS promotes and supports the rights of each patient:.. To access information contained in their medical record, unless restricted by law, within a reasonable time frame...To receive answers to questions about their medical record."

A hospital policy, "Plan for Provision of Care," approved 12/13/19, stated "Each patient who received care at SARMC can expect care as outlined in the Patient Rights Brochure." An undated hospital brochure, "Patient Rights & Responsibilities," stated "you have the right to ..."Access information in your medical record, unless restricted by law, within a reasonable timeframe."

An ED RN was interviewed on 3/03/20 at 8:30 AM. When asked what she would do if an ED patient asked for his or her medical record, she stated patients had a right to view their record and she would provide any reports that were available as soon as possible.

A Telemetry RN was interviewed on 3/03/20 at 9:00 AM. When asked what she would do if an inpatient asked for his or her medical record, she stated she would give the patient a request form to fill out, notify the charge nurse, who would notify the case manager, and she would document the request in her progress notes.

A second Telemetry RN was interviewed on 3/03/20 at 9:10 AM. When asked what she would do if an inpatient asked for his or her medical records, she stated she would notify the medical record team and they would follow policy. She would also document in her progress note and give the patient the telephone extension to medical records so they could call.

Internal hospital grievance documentation, stated Patient #2 had requested access to her medical records while in the ED on 2/12/20, and the ED provider had told her the records were incomplete, there was a process to get records, and medical records would be sent to her physician at discharge.

An RN progress note, dated 2/14/20, documented Patient #2, stated "her rights were being violated and that she wanted to see her health record." The RN documented responding "I told her she has every right to see her health records, I offered to call and get a person to come up and talk to her about logging on to the health portal." There was no documented follow-up as to whether Patient #2 was given access to her health record or whether Patient #2 changed her mind after making the requests, to explain why she was not given access.

There was no documentation Patient #2 was provided access to her medical record, upon request, during her ED visit or inpatient visit between 2/12/20 and 2/14/20.

The Director of Acute Care was interviewed on 3/03/20 between 8:15 AM and 9:30 AM. She stated Patient #2 was not given access to her record during the ED visit or hospitalization during her stay 2/12/20 through 2/14/20. She stated Patient #2 agreed to wait. She confirmed this information was not documented. She stated Patient #2 came in on 2/17/20, after discharge, and signed a request form and was given copies of her requested medical records.

Patient #2 was not given access to her medical records, upon oral request, within a reasonable time frame.

Based on policy review, medical record review, and staff interview, it was determined the hospital did not track and analyze for quality purposes an adverse patient event for 1 of 1 patients (Patient #2) with an adverse event and whose records were reviewed.

A hospital policy, "Event Reporting and Investigation Process -- SAHS," approved 2/27/20, was reviewed. It included the following information:
- "An event is an occurrence that is inconsistent with the normal or expected operation of the organization that either did, or could, adversely affect a visitor or patient, or a patient's planned care."

- "Reportable events include but are not limited to:.. medication variances...specimen variances."

- "Investigation and Follow-up:.. The following events will be monitored for trends:
a. Severity Level 1: Event has the capacity to cause harm.
b. Severity Level 2: Did not reach the patient.
c. Severity Level 3: Reached patient, no harm.
d. Severity Level 4: Increased patient monitoring, but no harm.
e. Severity Level 5: Temporary harm to patient, requiring treatment or intervention"

- The following events will be evaluated by risk management and the involved manager/supervisor to determine whether the medical condition or error contributed to the harm requiring a Root Cause Analysis and to determine next steps: a Severity Level 6: Temporary harm to patient and prolonged hospitalization..."

Patient #2 was a 52 year old female who arrived in the ED on 2/12/20 for evaluation after a motor vehicle accident.

An ED physician note for Patient #2, dated 2/12/20, stated: "Just prior to discharge the patient significantly felt lightheaded and unwell and her heart rate dropped into the 40s. Previous to this she had received a lidocaine patch as well as 1 dose of Flexeril 5 mg... Possibility of a medication reaction or vasovagal reaction are both quite reasonable but given that the patient has not rebounded sufficiently and feels unwell she will need to be monitored further. Case was discussed with internal medicine who gladly admit but request the involvement of cardiology."

The above referenced incident resulted in a 2 day inpatient admission for Patient #2. The surveyor requested a copy of an incident report or event report. None was provided. During an interview on 3/03/20 between 8:15 AM - 9:30 AM, the Director of Acute Care stated there was no incident report on the event.

The hospital did not track and analyze Patient #2's adverse event.

Based on record review, policy review, and staff interview, it was determined the agency failed to ensure nursing care met the needs of 1 of 6 patients (Patient #2) whose records were reviewed. This resulted in a delay in pain assessment and possible delay in pain intervention, a delay in obtaining a STAT urine screen, and a delay in removing a pain patch ordered removed on a STAT basis. Findings include:

Patient #2 was a 52 year old female evaluated in the ED on 2/12/20 after a MVA, and admitted to the telemetry floor for observation, after an episode of bradycardia following administration of pain medications, and prior to a planned discharge to home. Nursing care was not provided in a timely manner. Examples include:

1. There was no documented ED RN pain assessment of Patient #2, upon arrival 2/12/20 at 3:15 PM. The first documented pain assessment by an RN was on 2/12/20 at 4:49 PM. At that time Patient #2 rated her pain as 8 on a scale of 1-10 (considered severe pain). ED staff documented administering pain medication, per physician orders, as follows: morphine 2 mg IV push for pain at 2/12/20 at 4:49 PM, oral ibuprofen and oral Flexeril 5 mg at 2/12/20 at 4:57 PM, and a lidocaine topical patch at 4:59 PM. It could not be determined why Patient #2's pain was not assessed and addressed earlier. It was first documented as assessed and addressed an hour and a half after arrival in the ED.

2. An undated laboratory document, "Help Lab Improve Morning Collections," defined draw priorities. "STAT" was defined as "The main purpose for a stat order is an immediate clinical need that affects morbidity or mortality. There is a decision to be made immediately on the results of a test."

The "SAINT ALPHONSUS LABORATORY MANUAL," dated 2019-2020, included a section, titled "ORDERING REQUIREMENTS." It stated, "Please order 'STAT' for emergency testing only."

A hospital policy, "Medication orders -- SAHS," dated 1/31/20, described medication orders as "STAT, ASAP, or Routine." A "STAT order was described as "emergent...Response will be less than 15 minutes."

An ED RN was interviewed on 3/03/20 at 8:40 AM. When asked to explain her understanding of a STAT order, she replied "Now."

A Telemetry RN was interviewed on 3/03/20 at 9:00 AM. When asked to explain her understanding of a STAT order, she replied, "First priority."

A second Telemetry RN was interviewed on 3/03/20 at 9:10 AM. When asked to explain her understanding of a STAT order, she replied "it has to be done right away."

Two STAT orders were not carried out on a STAT basis.

a. A physician's order, dated 2/12/20 at 3:45 PM, for a nurse to collect Patient #2's urine for a STAT drug screen. There was an unexplained delay in collecting her urine for the STAT test. The urine was collected after admission to the Telemetry unit on 2/13/20 at 6:30 AM, over 14 hours after a STAT order, and after administration of narcotic medication for pain.

b. A physician's order, dated 2/12/20 7:48 PM, for a STAT removal of Patient #2's Lidocaine Patch. The Medication Administration Record documented removal of Patient #2's patch on 2/12/20 at 9:24 PM, over an hour and a half later.

The Director of Acute Care was interviewed on 3/03/20 between 8:15 AM and 9:30 AM. She confirmed the delays in carrying out the STAT orders for a urine toxicology screen and removal of the Lidocaine Patch.

Nursing staff did not address Patient #2's care needs in a timely manner.