HospitalInspections.org

Based on interview, review of grievance files and review of hospital policy, it was determined that the hospital failed to implement it's policy to ensure prompt resolution of grievances. The hospital's failure resulted in 6 of 6 grievance files reviewed not being completed within 30 days, per hospital policy, or having the required documentation as to why, also per hospital policy.

Findings include:

The hospital's list of grievances was reviewed and 6 files were selected for review, based on what appeared to be a complaint resolution time of greater than 30 days. The files were reviewed for content, including a letter to the complainant acknowledging receipt of the complaint, as well as documentation of the steps taken to resolve the complaint. All 6 of the files reviewed had taken greater than 30 days and one had taken almost 3 months. None of the files reviewed contained evidence of communication with the complainants as to why there was a delay in the complaint resolution.

Based on interview and review of grievance files, it was determined that the hospital failed to ensure that all complainants received written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital's failure to do so resulted 6 of 6 closure letters to complainants not having complete information regarding the resolution of their complaint and put future complainants at potential risk for same.
Findings include:
Six (6) of 6 grievance files reviewed were found to have final letters to complainants which were incomplete. None of the 6 letters contained the date of completion, and contained only the date the letter was written. All of the 6 letters were missing at least one of the required elements as described above. All files were reviewed with the Director of Quality and Risk, and with the Patient Advocate.

Based on interview and review of medical records, it was determined that the hospital failed to implement policies to ensure that all patients were protected from neglect. The hospital's failure to do so resulted in 2 of 10 patients whose medical records were reviewed, not being protected from neglect while in the ED.


Findings include:

Patient #1

Review of the medical record for Patient #1 revealed that the patient was an 84-year-old person who had been admitted to the ED for shortness of breath with frothy sputum. The patient's other diagnoses included dementia and non-insulin-dependent diabetes mellitus. The patient's medical record indicated that the patient had been in the ED for approximately 10 hours, but her/his blood glucose level had been checked only once, at 2:40pm, which was approximately an hour and a half after the patient was intially seen and triaged, and approximately 7 hours and 15 minutes before the patient was discharged from the ED at 9:55pm.

The Director of the ED, a Registered Nurse (RNs), was interviewed on October 16 and 17, 2012. The Director stated that, at a minimum, s/he would have rechecked the patient's blood glucose level before discharging the patient. The Director stated that there was not a policy in place to guide or direct RNs who cared for diabetics, as to how often a diabetic should have blood glucose levels rechecked.

Further review of the record revealed no documentation to support that the patient had been offered food or water during her/his 10 hours in the ED. There was also no documentation that the patient had been offered use of the bathroom or provided with incontinent care; no documentation that the patient had been offered ambulation or range of motion.

The patient's medical record was reviewed with the Chief Nursing Officer (CNO), the Director of the ED and the RN who provided care to the patient and discharged the patient from the ED.

The RN who provided care to the patient was unable to recall what care and services s/he had actually provided to the patient and acknowledged that is was not possible to ascertain from the documentation when s/he had assumed care of the patient.

Additional review of the medical record revealed an approximately 4-hour period of time when no licensed person, ie, a RN or physician, documented that the patient had been seen. The medical record had documentation from the first RN assigned to the patient at 4:16pm, with the first documentation from the RN assigned to care for the patient during the latter part of the patient's ED visit was at 10:13pm, a gap of approximately 4 hours.

Documentation provided by the complainant revealed that the patient had been returned to her/his living facility with a blood glucose level of 71 [normal range is approximately 60 to 120] and drenched in her/his own urine.

The CNO, Director of the ED and the RN who provided care to the patient all acknowledged that the care provided to the patient, as documented, did not meet minimum standards of nursing care.

Patient #3

Review of the medical record for Patient #3 revealed that the patient was a 31-year-old pregnant woman who had been admitted to the ED with jaw pain after an assault by a significant other. The medical record revealed that the patient reported a toothache, facial pain, an ear ache, jaw pain, a swollen jaw and "widespread dental decay". The record documented that the patient had sustained a fractured tooth as a result of the assault.

Discharge instructions included directions to "follow up with a dentist ASAP". Documentation did not indicate that the patient had been offered information regarding domestic violence, including a social worker evaluation or referral to shelters. Documentation did not indicate that the patient had been offered information about dentists or dental clinics that could have provided care and services for the patient's fractured tooth.

The Director of the ED was interviewed on 10/16 and 10/17/2012 and stated that s/he would have provided referrals to both domestic violence conselling/shelters and to dental care and acknowledged that the patient did not receive either from the RN assigned to care for the patient.

Based on interview, review of medical records and hospital documents, it was determined that the hospital failed to ensure that a Registered Nurse supervised and evaluated the nursing care for each patient. The hospital's failure to do so resulted in 2 of 10 patients who were seen in the hospital's Emergency Department (ED) not being provided with safe and appropriate care, and placed all patients of the ED at risk for the same.

Findings include:

Patient #1

Review of the medical record for Patient #1 revealed that the patient was an 84-year-old person who had been admitted to the ED for shortness of breath with frothy sputum. The patient's other diagnoses included dementia and non-insulin-dependent diabetes mellitus. The patient's medical record indicated that the patient had been in the ED for approximately 10 hours, but her/his blood glucose level had been checked only once, at 2:40pm, which was approximately an hour and a half after the patient was intially seen and triaged, and approximately 7 hours and 15 minutes before the patient was discharged from the ED at 9:55pm.

The Director of the ED, a Registered Nurse (RNs), was interviewed on October 16 and 17, 2012. The Director stated that, at a minimum, s/he would have rechecked the patient's blood glucose level before discharging the patient. The Director stated that there was not a policy in place to guide or direct RNs who cared for diabetics, as to how often a diabetic should have blood glucose levels rechecked.

Further review of the record revealed no documentation to support that the patient had been offered food or water during her/his 10 hours in the ED. There was also no documentation that the patient had been offered use of the bathroom or provided with incontinent care; no documentation that the patient had been offered ambulation or range of motion.

The patient's medical record was reviewed with the Chief Nursing Officer (CNO), the Director of the ED and the RN who provided care to the patient and discharged the patient from the ED.

The RN who provided care to the patient was unable to recall what care and services s/he had actually provided to the patient and acknowledged that is was not possible to ascertain from the documentation when s/he had assumed care of the patient.

The CNO, Director of the ED and the RN who provided care to the patient all acknowledged that the care provided to the patient, as documented, did not meet minimum standards of nursing care.

Patient #3

Review of the medical record for Patient #3 revealed that the patient was a 31-year-old pregnant woman who had been admitted to the ED with jaw pain after an assault by a significant other. The medical record revealed that the patient reported a toothache, facial pain, an ear ache, jaw pain, a swollen jaw and "widespread dental decay". The record documented that the patient had sustained a fractured tooth as a result of the assault.

Discharge instructions included directions to "follow up with a dentist ASAP". Documentation did not indicate that the patient had been offered information regarding domestic violence, including a social worker evaluation or referral to shelters. Documentation did not indicate that the patient had been offered information about dentists or dental clinics that could have provided care and services for the patient's fractured tooth.

The Director of the ED was interviewed on 10/16 and 10/17/2012 and stated that s/he would have provided referrals to both domestic violence conselling/shelters and to dental care. The Director stated that there was not a policy in place to direct or guide ED staff regarding referrals for patients who were victims of domestic violence and/or who needed dental care "ASAP".

The documentation in the medical record of both patients did not contain evidence that a RN had assessed/reassessed/evaluated the patients and made the appropriate interventions for nursing care of the patients.


Ref. A0392

"The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient."