HospitalInspections.org

Based on record review and interview the facility failed to follow their process for patient complaints citing two out of two records reviewed (ID #s 1 and 6).

Findings:

In an interview on 12/6/10 at 2:50 PM, the complainant stated she "complained to the hospital and they said they would look in to it." She stated she never received an acknowledgement or response from the hospital.

Record review of a form entitled "Customer Experience Tracking - All Grievances" revealed three complaints made in October 2010 had a status of "Open." Two of the complaints were made on 10/8/10 on behalf of patient # 1 and listed the types as "med-concern/issue" and "treatment - concern/issue." The log also revealed a complaint made on 10/13/10 on behalf of patient # 6 that was listed as "clinical concerns, professionalism, and test/procedure concern/issue."

In an interview on 12/9/10 at 11:55, personnel # 51 stated that a letter acknowledging the receipt of the complaint for patient # 1 was not sent due to a lack of contact information for the complainant. Personnel # 51 further stated that the complaint was not investigated or resolved. Personnel # 51 also stated the normal procedure is to respond to the complainant in seven days then to resolve the complaint within thirty days.

In an interview on 12/9/10 at 12:35, personnel # 53 stated that a letter was sent to the complainant (patient # 6) acknowledging receipt of the complaint. Personnel # 53 also stated that nothing else was done related to the complaint.

Record review of a Memorial Hermann Northwest Hospital policy entitled "Customer Complaints/Concerns: Response to" (original date 3/1/1997, Last Review Date 11/24/10) revealed:
"Within seven (7) calendar days of the receipt of a written grievance, the complainant will be contacted by the patient representative/patient relations department to acknowledge that the grievance has been received and to provide an approximate time frame for processing the grievance. A written acknowledgment is sent." The policy further states "Every effort will be made to resolve the grievance in an expeditious manner. The investigation and resolution of a grievance should ordinarily be completed within 30 business days from the date the grievance was received. The patient representative will contact the complainant if it appears the investigation may take longer than thirty (30) business days."

Based on review of medical records, interviews, and review of applicable policies, the RN did not supervise and evaluate the nursing care on 5 of 5 patients (Patient #'s 1 - 5, closed records), in that patients # 1-4 did not receive oral care per policy and the staff did not report the patient ' s ulcer to the physician or obtain a wound culture per policy, and patients 1-5 were not turned and repositioned every 2 hours.

Findings:

Record review of a facility policy entitled "Electronic Nursing Documentation and Intervention Documentation Frequency" (original date 7/10/09, last review date 11/2/10) revealed: "General Interventions Documentation -...c. Daily and as activity occurs for patient i. Hygiene, ii. Activities of Daily Living... iv. Positioning NOTE: If patient cannot reposition himself/herself, he/she must be repositioned at least every two hours."

Record review of the medical record for patient # 1 revealed the patient was admitted with a diagnosis of new left hemiparesis (partial paralysis affecting one side of the body). According to the "Frequent Nursing Interventions" form in the medical record, the patient was only repositioned at the following dates and times:
10/1/10 at 5:38 AM
10/1/10 at 2:27 PM
10/1/10 at 9:35 PM
10/1/10 at 11:30 PM
10/2/10 at 8:02 PM
10/3/10 at 00:01 AM
10/3/10 art 4:00 AM
10/3/10 at 8:14 PM
10/4/10 at 00:08 AM
10/4/10 at 4:04 AM
10/4/10 at 12:53 PM
10/4/10 at 3:58 PM
10/5/10 at 9:22 AM
10/5/10 at 12:20 PM
10/5/10 at 8:00 PM
10/6/10 midnight
10/6/10 at 8:30 PM
10/7/10 at 00:40 AM
10/7/10 at 4:17 AM
10/7/10 at 6:52 AM

Oral care for patient # 1 was provided as follows:
10/1/10 at 12:34 PM, 10/2/10 none, 10/3/10 at 8:14 PM, 10/4/10 none, 10/5/10 8 PM, 10/6/10 at midnight, and 10/7/10 at 05:59 AM.

Patient # 2 was admitted with a diagnosis of Cerebrovascular Accident (CVA, stroke) and was assessed to require total assistance. The medical record revealed the patient was repositioned on 10/6/10 at 00:48 AM, 6:20 AM, 7:55 AM, 11:25 AM, 12:24 PM, and 5:51 PM. The patient was not repositioned again until 10/7/10 at 4:08 AM then at 3:00 PM. No oral care was documented during this timeframe.

Patient # 3, 98 years old, was admitted with a diagnosis of Congestive Heart Failure, rule out acute coronary syndrome. According to the medical record, the patient was admitted on 10/2/10 at 5:45 PM and was repositioned at 10 PM and midnight, then on 10/3/10 at 4:00 AM, 6:00 AM, 11:40 AM, 4:26 PM, then at 00:12 AM on 10/4/10. No oral care was documented during this timeframe.

Patient # 4 was admitted on 10/4/10 at 6:50 PM with diagnoses of CVA (stroke), weakness, falls. The assessment varied from "walks occasionally" to requiring moderate assistance, maximum assistance, and total assistance. According to documentation from 10/4/10 at 1:59 AM to 10/7/10 at 06:10 AM, the patient was first repositioned on 10/6/10 at 00:05 AM, then again at 4:00 AM. Oral care was documented at 4:55 PM on 10/5/10.

Patient # 5 was admitted 10/4/10 at 12:00 PM with diagnoses of Chest Pain and CVA (stroke). The nursing assessment regarding the patient ' s mobility varied from requiring one-person assistance, to moderate assistance, minimum assistance, and being independent. Repositioning was documented on 10/4/10 at 3:30 PM, 8:00 PM, Midnight, 10/5/10 at 7:16 AM, 5:54 PM, 8 PM, Midnight, and 10/6/10 at 9:58 AM, then nothing through midnight.

During the electronic medical record review on 12/9/10 at 11:50 AM, personnel # ' s 51 and 55 acknowledged the documentation reflecting that patients 1-5 were not repositioned every two hours and that oral care was not provided daily.

During an interview on 12/9/10 at 1:10 PM, personnel # 54 acknowledged the documentation reflecting the lack of repositioning and oral care.

Review of the facility's Skin Integrity Risk revealed At Risk (score of 15-18 interventions include "Frequent turning...", Moderate Risk (Score 13-14) interventions include "...turning schedule," and High Risk (Score 10-12) interventions include "...increase frequency of turning..."

Record review of patient # 1 revealed documentation reflecting the patient's Skin Integrity Risk score ranged from 13 to 19 during his hospital admission.

Review of a facility policy entitled "Skin/Wound Management" (last review date 7/31/08) revealed: "For draining wounds, call physician for consideration of a baseline wound culture." The policy also stated "Notify physician for a Stage II or greater pressure ulcer, and obtain a physician order for treatment."

Record review of patient # 1 ' s medical record revealed: On 10/6/10 at 8:06 AM and again at 10:45 PM, nursing documentation of the skin assessment revealed: "Skin not intact, pressure ulcer, sacral Stage II, red drainage." Documentation on 10/7/10 at 9:00 AM stated "Skin not intact, pressure ulcer, sacral Stage II."

In an interview on 12/9/10 at 1:50 PM, personnel # 55 stated that the patient ' s record did not contain an order for a wound culture and that the physician was not notified of the Stage II ulcer.