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Based on record review and interview the facility failed to ensure effective implementation of the grievance process for prompt resolution of patients' grievances as evidenced by failing to determine correctly whether a patient's concerns were a complaint or grievance for 2 (Patient #2 and R#1) out of 4 grievances reviewed.

Findings:
Review of the complaint filed by the son of Patient #2 at the hospital revealed in part, " ...S15Housekeeping Supervisor reported he had made two visits with Patient #2 while she was in the hospital and had spoken to the son also. The son had called him this morning (11/15/13) and was irate about some nursing issues upon his mother's discharge yesterday. I told him I would inform S5Patient Care Representative ..." Further review of the complaint/grievance revealed Patient #2's son concerns were classified as a complaint not as a grievance.

Review of the complaint filed by R#1's daughter on 10/16/13 revealed in part, "...I spoke with the daughter of R#1 and she explained the following regarding a staff RN.....When the nurse entered the patient's room she complained about the smell and made a comment about what housekeeping mops the floors with smells bad and it bothers her allergies....The nurse started reviewing the medications with the daughter, the daughter stated those meds she takes during the day ...the nurse explained she was looking at the evening list not the day list....The nurse's demeanor seemed confused, mixed up, and very disorganized...She was at the bedside giving report to another nurse and the daughter stopped her and said it didn't apply to her mother...The night before the patient was discharged, the patient's son stayed with the patient. He hit the call light one time and no one came to the bedside. He had to call again....When the daughter arrived to her mother's room, her mother's sheets were wet, but her mother was dry..." Further review of the complaint/grievance revealed R#1's daughter's concerns were classified as a complaint not as a grievance.

An interview was conducted with S13Foundation Patient Relations Director on 12/3/13 at 2:30 p.m. She reported she was the person that labels if an issue is a complaint or a grievance. S13 agreed Patient #2's son's concerns and R#1's daughter's concerns should have been labeled as a grievance not as a complaint.

Based on record review and interview the facility failed to ensure the medical staff enforced the by-laws and the rules and regulations adopted by the medical staff as evidence by a medical staff member not assessing an acute care inpatient patient every 24 hours for 6 out of 6 patients (Patient #1-#6) reviewed for a physician assessment every 24 hours out of a sample of 8.
Findings:

Review of the Rules and Regulations for the Medical Staff of the Hospital revealed in part, " ...Admitting/Attending Physician: Patients on inpatient acute care units will be seen at least once every 24 hours by the admitting /attending physician or by his/her covering physician who has equivalent privileges ... "

Patient #1

Review of the electronic medical record for Patient #1 revealed she had been admitted to the hospital on 11/18/13 for Left Total Hip Arthroplasty (replacement) and discharged on 11/21/13. Further review revealed Patient #1 had no documented evidence of a visit or an assessment by S10MD on the day of discharge in her medical record.

Patient #2
Review of the electronic medical record for Patient #2 revealed she had been admitted to the hospital on 11/11/13 for a Right Total Hip Arthroplasty (replacement) and discharged on 11/14/13. Further review revealed Patient #2 had no documented evidence of a visit or an assessment by S10MD or another physician on the day of discharge in her medical record.
A phone interview was conducted with S9NP (Nurse Practitioner) on 12/3/13 at p.m. S9NP reported he worked for S10MD. He reported in the orthopedic practice they typically do not see the patients with a hip replacements on Post-op Day #3 and none of the NPs or the MDs saw Patient #2 on Post-op Day #3 prior to discharge.

A phone interview was conducted with S10MD on 12/3/13 at 3:15 p.m. He reported he routinely gives discharge orders over the phone. He went on to report most hospitals he was familiar with, the physician must see the patient every calendar day, not every 24 hours. He continued to report since Patient #2 was discharged on 11/14/13, it wasn't a complete calendar day and he was unable to see the patient prior to discharge.

Patient #3
Review of the electronic medical record for Patient #3 revealed he had been admitted to the hospital on 11/18/13 for Left Total Hip Arthroplasty (replacement) and discharged on 11/21/13. Further review revealed Patient #3 had no documented evidence of a visit or an assessment by S10MD on the day of discharge in his medical record.

Patient #4

Review of the electronic medical record for Patient #4 revealed she had been admitted to the hospital on 11/18/13 for Left Total Knee Revision and discharged on 11/21/13. Further review revealed Patient #4 had no documented evidence of a visit or an assessment by S10 MD on the day of discharge in her medical record.

Patient #5
Review of the electronic medical record for Patient #5 revealed she had been admitted to the hospital on 11/18/13 for Left Total Knee Replacement and discharged on 11/21/13. Further review revealed Patient #5 had no documented evidence of a visit or an assessment by S10 MD on the day of discharge in her medical record.

Patient #6

Review of the electronic medical record for Patient #6 revealed he had been admitted to the hospital on 11/18/13 for Left Total Knee Replacement and discharged on 11/21/13. Further review revealed Patient #6 had no documented evidence of a visit or an assessment by S10MD on the day of discharge in his medical record.

An interview on 12/3/13 at 1:30 p.m. with S2CNO indicated there was no documented evidence in Patients' #1, #3, #4, #5, & #6 medical records that S10MD rounded (visited)/ or examined the patients on the date of discharge. According to S2CNO all patients should be seen by a physician daily and the above mentioned patients were not.

An interview on 12/3/13 at 2:00 p.m. with S12RN indicated it is the practice of S10MD not to visit or examine patients on the day of discharge. S12 RN confirmed there was no documented evidence that the above mentioned patients were visited or examined by S10 MD on the date of discharge.

An interview was conducted with S11MD, President of the Medical Staff of the hospital on 12/3/13 at 12:30 p.m. He reported he would expect an admitting physician to assess his/her patients once a day. He went on to report a nurse practitioner was a good tool to assist the physician, but ultimately the physician was responsible. The physician needs to assess the patients on the last day of the hospital stay prior to discharging the patients. S11MD went on to report, he would not expect a physician to discharge a patient with a verbal order if they had not assessed the patient on the day of discharge.















31206

Based on record review and interview the hospital failed to reassess a patient's discharge plans as evidenced by not having a system in place in which an ongoing discharge assessment was conducted for 1 (Patient #2) out of 6 patients (Patient #1-6) reviewed for discharge planning.

Findings:
Review of the hospital's policy on Care Management in part revealed, "...The Care Manager provides an initial and ongoing evaluation of all patients to assure medical necessity in the appropriate level of care. The Care Managers' primary objective is to coordinate the entire continuum of care plan for the patient...Referral for further screening by appropriate discipline will then be made when issues regarding diagnosis, wellness progression, or psychosocial circumstances can not be resolved through standard interventions..."

Patient #2 was an 84 year old female who electively had a Right Total Hip Replacement on 11/11/13 due to severe pain in her right hip with weight bearing activities. Patient #2 was discharged home on 11/14/13.

An interview was conducted with S6RN on 12/3/13 at 11:30 a.m. She reported she discharged Patient #2 from the hospital on 11/14/13. She went on report when she told Patient #2's son his mother was going to be discharge that day, he seemed a little surprised and upset.

An interview was conducted on 12/3/13 at 8:40 a.m. with S5RN, Case Manager. S5RN stated she was the case manager for Patient #2 during her hospital stay. She reported the nurses do an admission assessment on admit and certain answers to questions during the assessment will trigger either a case manager referral or a social worker referral. In this case, S5RN stated, the physician ordered a Discharge planning/case manager referral for the patient. S5RN continued to report she spoke with Patient #2 on Post-op Day #1 and ordered her a rolling walker and a bedside commode, because the patient stated she did not have those items. She further reported that typically S10MD doesn't order physical therapy or home health after discharge from the hospital, unless he sees a need. S5RN stated she did ask if the patient wanted home health and she stated she did not want home health. S5RN reported home health didn't seem to be needed with Patient #2, since the patient stated she would be staying with family after her discharge from the hospital. If the patient is ambulating prior to discharge, S10MD typically doesn't order physical therapy either. He gives his patients a 2 week follow up appointment prior to having the surgery. S5RN went on to report she didn't ask if the patient had stairs at the home she would be discharged to, since physical therapy takes care of that. If the patient has stairs at the home; the physical therapist will bring mobile stairs to the patient's room to instruct them on how to climb the stairs. S5RN further reported she went to see the patient on Post-op Day #3 to see if her DME (durable medical equipment) had arrived; and it had. She stated she remembered introducing herself to the son. The patient was in the recliner at that time and was irritated with her restless leg syndrome. She didn't remember any other complaints by the family. S5RN stated she remembers speaking to S8RN (who was the charge nurse that day) and S7PT. S7PT stated she would recommend the patient having home health, due to her being weak with exercise. S5RN stated she passed the information on to S8RN. S8RN stated she would have Patient #2's nurse, S6RN, call S9NP. When questioned if she was aware that Patient #2's son was concerned about bringing Patient #2 home from the hospital, she stated she was not, but she should have been notified.

An interview was conducted with S6RN on 12/3/13 at 09:50. She reported on the day of discharge she contacted S9NP at about 11:30 a.m. about the patient 's concerns about going home. S6RN reported she suggested home health and/or lab work prior to discharging the patient. S9NP reported he was aware of the patient 's vital signs, lab work and progress with physical therapy and if the patient became weak or tacycardic at home, they could call the office. S9NP did not order home health for the patient.

An interview was conducted with S15RN, Clinical Analyst for IT (Information Technology) on 12/3/13 at 9:45 a.m. She reported once the initial nursing assessment was done and the case manager referral was triggered in the system, if the patient's condition or needs changed during the course of the hospital stay, there was not a system in place which triggered a continuous reassessment of the discharge plan for the nurses.