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Based on review of the grievance process and administrative interview, the facility failed to specify an appropriate timeframe for the resolution of a grievance and the provision of a written response for 10 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 10 patient records reviewed.

The findings include:

Record reviews on 12/12/11 and 12/13/11 for ten (10) patients who had filed a grievance with the facility revealed the following: Patient #1 had filed a grievance on 10/26/11 with no written resolution letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution letter documented as sent to date; Patient #3 had filed a grievance on 10/28/11 with no written resolution letter documented as sent to date; Patient #4 had filed a grievance on 11/7/11 with no written resolution letter documented as sent to date; Patient #5 had filed a grievance on 10/17/11 with no written resolution letter documented as sent to date; Patient #6 had filed a grievance on 10/5/11 with no written resolution letter documented as sent to date; Patient #7 had filed a grievance on 10/14/11 with no written resolution letter documented as sent to date; Patient #8 had filed a grievance on 9/8/11 with no written resolution letter documented as sent to date; and Patient #10 had filed a grievance on 11/28/11 with no written resolution letter documented as sent to date.

During various interviews with the Chief Nursing Officer, Administrative Director of Quality & Outcomes Management, and Administrative Director of Risk Management confirmed no response letters had been sent to these ten (10) patients as required.

The facility provided a copy of the Policy and Procedure entitled "Grievance/Concerns Identified by Patient/Representative" Policy No. P-10-003-R1 Revised 6/11 with the following notation:
Definitions:
"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, or the patient's representative regarding the patient care, abuse or neglect, issues related to the hospital compliance with the CMS Hospital Conditions of Participation (CoP)...Complaints received in any form become a grievance is not resolved by staff present."
Procedures:
II Grievance Process
3. "If the employee who received the complaint/concern is unable to manage the resolution for the patient/family the employee should notify his/her immediate supervisor (e.g. Nurse Director, Administrative Director) of the complaint/concern....
c. Those Directors to whom the documentation of the concern has been sent are responsible for the investigation, resolution if possible, and complete follow up within 30 days. All completed documentation is to be done on the Patient Concern Log.
Responsibilities:
II. The Department Director is responsible to see that all complaints and concerns are resolved, if possible, and documented within 7 days. A written response, within 30 days is to be sent if the grievance cannot be immediately resolved or not resolved prior to discharge.

Regulations specify that the hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame. On average, a time frame of 7 days for the provision of the response would be considered appropriate. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible.

Review of the facility's "Patient Concern Log" for the 3rd and 4th Quarter on 12/13/11 contained a total of 87 entries with 28 additional entries (38 total) that revealed a column entitled "Date Letter Sent" with a notation of "None." There was no documentation provided/submitted that demonstrated the facility had written and sent a resolution letter to each of the patients listed in a timely manner (within the appropriate timeframe of 7 days).

Based on review of the grievance process and administrative interview, the facility failed to provide, in its resolution of the patients grievance, a written notice of its decision that contained the name of the hospital contact person, steps taken in the investigation, the results, and date of completion for 10 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 10 patient records reviewed.


The findings include:

Record reviews on 12/12/11 and 12/13/11 for ten (10) patients who had filed a grievance with the facility revealed the following: Patient #1 had filed a grievance on 10/26/11 with no written resolution notice/letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution notice/letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution notice/letter documented as sent to date; Patient #3 had filed a grievance on 10/28/11 with no written notice/resolution letter documented as sent to date; Patient #4 had filed a grievance on 11/7/11 with no written notice/resolution letter documented as sent to date; Patient #5 had filed a grievance on 10/17/11 with no written notice/resolution letter documented as sent to date; Patient #6 had filed a grievance on 10/5/11 with no written notice/resolution letter documented as sent to date; Patient #7 had filed a grievance on 10/14/11 with no written notice/resolution letter documented as sent to date; Patient #8 had filed a grievance on 9/8/11 with no written notice/resolution letter documented as sent to date; and Patient #10 had filed a grievance on 11/28/11 with no written notice/resolution letter documented as sent to date.

The facility provided a copy of the Policy and Procedure entitled "Grievance/Concerns Identified by Patient/Representative" Policy No. P-10-003-R1 Revised 6/11 with the following notations:
Definitions:

"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, or the patient's representative regarding the patient care, abuse or neglect, issues related to the hospital compliance with the CMS Hospital Conditions of Participation (CoP)...Complaints received in any form become a grievance if not resolved by staff present."

* "When the patient of patient's representative request their complaint be handled as formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply."

Review of the facility's "Patient Concern Log" for the 3rd and 4th Quarter on 12/13/11 contained a total of 87 entries with 28 additional entries (38 total) that revealed a column entitled "Date Letter Sent" with a notation of "None." There was no documentation provided/submitted that demonstrated the facility had written/sent a resolution letter to each of the patients listed and had complied with the regulation.

During various interviews with the Chief Nursing Officer, Administrative Director of Quality & Outcomes Management, and Administrative Director of Risk Management confirmed no response letters had been sent to these ten (10) patients as required. In other interviews with the Administrative staff, they reported that they verbally communicate with each complainant.

Regulations specify that the hospital must provide the patient with a written notice of its decision that contained the name of the hospital contact person, steps taken in the investigation, the results, and date of completion. While the facility may use any additional tools they deem necessary to resolve a grievance, the facility, in all cases, must provide a written notice (response) to each patient's grievance (s). The written response must contain the elements listed in this requirement.

Based on staff interview and medical record review, the facility failed to ensure the patient/family participated in the development, implementation and revision of the care plan process with regard to care needs due to health status changes for 3 (Patients #1, #6, and #8) of 10 patient records reviewed.


The findings include:

1. Review on 12/12/11 for Patient #1 revealed the patient was admitted to the hospital on 10/21/11 with a diagnosis of Hydronephrosis (kidney disease) and discharged on 10/25/11. Review of the clinical record revealed the patient was sent to a medical floor upon admission. Nursing documentation revealed at approximately 7:00 p.m. the patient's oxygen was set at 4L/nc (nasal cannula) and saturation level at 93%, the abdomen was slightly distended. The patient was complaining of abdominal discomfort from the CBI (continuous bladder irrigation) with notation the CBI was stopped at this time. Orders were received for bladder irrigation with patient reporting "feeling much better." At 8:00 p.m. the nursing documentation indicated the patient was receiving the first unit of a blood transfusion with the abdominal condition noted as "hypo bowel sounds, and oxygen set at 2L/nc with sats at 92-93% (no order noted for decrease in oxygen rate). Family was noted as being at the bedside at this time. At midnight, the nurse documented the second unit of blood completed, uneasy breathing with oxygen sats at 93% (no nasal cannula level documented). At 2:20 a.m., the next nursing documentation noted audible wheezing, patients sats "very low" at this time with the patient put on a non-rebreather, head in up position, appears very pale and distressed, Code H called with physician notified and orders received. The patient's condition began to change on 1022/11 at 8:00 p.m. until sent to the ICU (Intensive Care Unit) on 10/23/11 at 3:00 a.m. There was no evidence in the record the patient/family was given an opportunity to participate in the on-going development, implementation and revision of the care plan (from 10/22/11 to 10/23/11) to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care.

2. Review on 12/12/11 for Patient #6 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. "On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets." Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote any changes in the patient's condition with reference to any health status changes (bleeding from the right groin site). There was no evidence the family was notified of the change in condition prior to the ICU transfer. There was also no evidence they were given an opportunity to participate in the on-going development, implementation and revision of the care plan to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care.

3. Review on 12/12/11 for Patient #8 revealed the patient was admitted to the hospital on 7/30/11 with a diagnosis of Right Hip Pain s/p Fall and discharged on 8/17/11. Review of the clinical record revealed the patient was sent to a surgical floor upon admission with Buck's traction. Physician's Discharge Summary dated 8/17/11 revealed the patient had a repair of the right hip on 8/2/11. Post-op the patient was sent to the cardiac floor due to rapid atrial fibrillation (irregular heart beat) second to sinus tachycardia (fast heart rate). On 8/8/11, the patient had elevated liver function studies and underwent an Endoscopy procedure. On 8/11/11, the patient was found to have an incarcerated incisional hernia and was taken to the Operating Room for repair.

Documentation in the nurses notes revealed on 8/11/11 at 5:00 p.m. the surgeon was informed of the patient's status with orders received. Post-op repair the patient went into respiratory failure and was intubated and sent to ICU at 6:00 p.m. for close monitoring. There was no evidence the family was aware of the patient's serious condition and notified of the patient's whereabouts prior to the ICU transfer. There was also no evidence in the record the patient/family was given an opportunity to participate in the on-going development, implementation and revision of the care plan (from 8/11/11 to 8/17/11) to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care.

Based on clinical record review and administrative interview, the hospital failed to maintain an effective on-going hospital wide, data-driven Quality Assessment Program that monitors the effectiveness and safety of the service and quality of care the facility provides as it relates to the "Grievance Process and Resolutions." This failure presents a substantial probability to adversely affect all patients' physical health, safety and well-being.
Interviews with the hospital's Administrative Director of Quality throughout the survey process (12/12/11 through 12/13/11) failed to reveal the existence of a definitive program that addressed tracking and trending for Risk Management's written responses to patients' or the representatives' grievances/complaints filed during the 3rd and 4th quarter of 2011.

Per the facility's Policy and Procedure Information entitled "Grievance/Concerns Identified by Patient/Representative" Policy No. P-10-003-R1 Revised 6/11 with the following notation:
Responsibilities: IV. QM/RM (Quality Manager/Risk Manager) reviews the Patient Concern Log and Meditech Notifications of grievance and concerns and reports findings to the QCC (Quality Coordinating Council) quarterly. QM/RM is available to assist with the preparation of response letters by the Department Directors.
There was no evidence provided of any review of the Patient Concern Log to demonstrate the QAPI (Quality Assurance Performance Improvement) program recognized the facility had a grievance process and resolution problem and thus, monitored the effectiveness and quality of care to the patients the hospital serves.

Based on record review for 4 out of 10 sampled patients, administrative interview, and review of accepted standards of nursing practice and care, it was determined the facility failed to (1) ensure the registered nurse supervised and adequately evaluated the nursing care and care plan as it relates to assessments for the patient (Patient #1), (2) notify physician and patient's representative of care needs and health status changes (Patients #1 and #6), and (3) document the patient's skin/wound care interventions (Patients #3 and #4). This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

Florida Statutes, Chapter 464 Part 1 (3)(a) reads: " 'Practice of professional nursing' means the performance of those acts requiring specialized knowledge, judgment, and nursing skill based upon applied principles of biological, physical, and social sciences which shall include, but not be limited to:
1. The observation, assessment, nursing diagnosis, planning, intervention and evaluation, health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.
2. The administration of medications and treatments as prescribed or authorized by a licensed practitioner authorized by the laws of this state to prescribe medications and treatments.
3. The supervision and teaching of other personnel in the theory and performance of above acts


The findings include:

1. Review on 12/12/11 for Patient #1 revealed the patient was admitted to the hospital on 10/21/11 with a diagnosis of Hydronephrosis (kidney disease) and discharged on 10/25/11. Review of the clinical record revealed the patient was sent to a medical floor upon admission. Nursing documentation revealed at approximately 7:00 p.m. the patient's oxygen was set at 4L/nc (nasal cannula) and saturation level at 93%, the abdomen was slightly distended. The patient was complaining of abdominal discomfort from the CBI (continuous bladder irrigation) with notation the CBI was stopped at this time. Orders were received for bladder irrigation with patient reporting "feeling much better." At 8:00 p.m. the nursing documentation indicated the patient was receiving the first unit of a blood transfusion with the abdominal condition noted as "hypo bowel sounds, and oxygen set at 2L/nc with sats at 92-93% (no order noted for decrease in oxygen rate). Family was noted as being at the bedside at this time. At midnight, the nurse documented the second unit of blood completed, uneasy breathing with oxygen sats at 93% (no nasal cannula level documented). At 2:20 a.m., the next nursing documentation noted audible wheezing, patients sats "very low" at this time with the patient put on a non-rebreather, head in up position, appears very pale and distressed, Code H called with physician notified and orders received. The patient's condition began to change on 10/22/11 at 8:00 p.m. until sent to the ICU (Intensive Care Unit) on 10/23/11 at 3:00 a.m. There was no evidence in the record the registered nurse effectively evaluated the change in the patient's condition on an on-going basis from 8:00 p.m. (10/21/11) to 2:20 a.m. (10/22/11) and contacted the physician for further guidance and orders during that time. There was no evidence the family was notified of the change in condition prior to the ICU transfer.

2. Review on 12/12/11 for Patient #3 revealed the patient was admitted to the hospital on 10/26/11 with a diagnosis of Right Infected Knee d/t Total Knee Arthroplasty.

Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed admission notes dated 10/26/11 at 5:46 p.m. reporting an abrasion on the right buttock with no dressing in place and left open to air. The next documentation in the record was written on 10/26/11 at 8:00 p.m. noting the skin was "pale, warm, dry, and good turgor" with no mention of any abrasion to the right buttocks. On 10/27/11 at 8:00 a.m. the nurse documented the skin as "appropriate for patient, warm, dry, and good turgor" without mention of the right buttock skin abrasion.

On 10/28/11 at 8:30 p.m. the nurse documented there was an abrasion to the right buttock. Further review of the record revealed a physician's order dated 10/27/11 for the nurse to change the dressing and clean with betadine twice daily. Documentation in the nurses notes for 10/27/11 revealed the nurse provided wound care using an abdominal dressing pad with tape and failed to use betadine as ordered. There was no evidence in the record the registered nurse effectively evaluated the change in the patient's condition on an on-going basis and contacted the physician for further guidance and orders.

3. Review on 12/13/11 for Patient #4 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease.

Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. "On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets." Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote any changes in the patient's condition with reference to any health status changes (bleeding from the right groin site). There was no evidence the family was notified of the change in condition prior to the ICU transfer.

4. Review on 12/12/11 for Patient #6 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. "On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets." Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote the registered nurse evaluated the patient for any changes in the condition with reference to bleeding from the right groin site. There was no documented evidence the physician and the family were notified of this change in condition prior to the Code Blue on 8/17/11 at 2:40 p.m.