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Based on record reviews and interviews the hospital failed to identify a patient's representative complaints as a grievance, conduct a thorough investigation and provide a written response to the patient's representative for 1(#3) of 5 grievances reviewed. Findings:

Review of the closed record for patient #3 reflected a 47 year male admitted to the hospital on 3/14/13 with the diagnoses : Shortness of Breath, Cirrhosis of Liver, Pulmonary Embolism/Infarct, Ascites, Thrombocytopenia, Chronic Kidney Disease Stage IV(Severe), Acute Renal Failure Unspecified, Obstruction of Bile Duct, Polycystic Kidney Disease, Long Term(Current) use of Antiplatelet/Antithrombotic, Long-term(Current) use of steroids, Hyperlipidemia, Hyperkalemia, Esophageal Reflux, and Iatrogenic Hypotension and was discharged by virtue of death on 3/22/13.

Review of the grievance logs revealed no grievance documented for patient #3.

Review of a document presented by S10Risk/Safety Management on 7/30/13 at 3:30 p.m. which she identified as notes taken by S13MD CMO/VPMA on 4/15/13 during an interview with patient#3's wife, revealed a hand written document. The document had a date of 4/15/13, patient#3's name, patient #3's wife's name and contact #, and the following questions listed:
1) Compression device never applied or ordered?
2) Nebulizer ordered first time before death?
3) No bath x 8 days by staff
4) Transfer delayed 24 hours -her biggest concern
5) Monitor strips

Review of e-mails presented by S10Risk/Safety Management on 7/30/13 at 3:30 p.m. which she defied as scheduled meetings which were set-up by her to help find answers to the questions which the patient's wife had requested.
Review of the e-mails revealed the staff held meetings on the following dates:
1) S13MD CMO/VPMA first meeting with the patient's wife 4/15/13. (Notes)
2) Meeting on 5/8/13 (subject patient #3 )review with required attendees of S13MD CMO/VPMA, S15Case Management Director, S7Unit Coordinator 3N, and S13MD CMO/VPMA's secretary.
3) Meeting on 5/20/13 (no subject) with S14MD Hospitalist, and Nurse Practitioner.
4) Meeting on 5/21/13 chart review with S14MD Hospitalist, and Nurse Practitioner.
5) Meeting on 6/10/13 subject patient #3's wife -required attendees S10Risk/Safety Manager, S13MD CMO/VPMA, S15Case Management, and S16Adm.Assist.
Further review of the e-mails revealed on 6/10/13 the patient's wife was included as the subject of the meeting.

Interview on 7/30/13 at 3:30 p.m. with S10Risk/Safety Management revealed she recalled having 2 face-face conversation/meeting (5/20/13 & 6/10/13) and 3 telephone conversations( not certain of the exact dates) with patient #3's wife after his death (3/22/13). She stated that she was unable to recall if she had ever contact the patient's wife to only give her updates on the ongoing investigation and findings. When asked if she had any documentation of the meetings and telephone calls she replied "no". She confirmed the e-mails were all that she had indicating that efforts were being made to find answers to the questions which the patient's wife had requested (4/15/13).
S10Risk/Safety Management confirmed that meetings were held as scheduled on the e-mails for record review, and discussion she was not able to recall if any line staff (CNAs, Floor Nurses) had been interview and or involved in the investigation. When ask if they should have her reply was "yes." According to S10Risk/Safety Management the patient's wife was only extended an invitation to the meeting on 6/10/13 for the purpose of providing the patient's wife with an explanation of the transfer process, transfer as it related to the patient, and care of the patient during the hospital. She stated in attendance were S10Risk/Safety Management, S14MD Hospitalist, S15Case Management, Nurse Practitioner, and Regional Vice President of Clinical Operations, S13MD CMO/VPMA did not attend (out sick/personal). According to S10Risk/Safety Management, S14MD Hospitalist went over care of the patient, explained the transfer process, treatment rendered during the course of the patient's hospital stay, and transfer as it related to the patient. She also informed the patient's wife that the team had concluded the SCD hose were ordered and not placed on the patient, and the transfer was not necessary it was not urgent nor an emergency.

A telephone interview was conducted on 7/31/13 at 10:15 a.m. with S13MD CMO/VPMA confirming that the notes dated 4/15/13 were notes written by him during a face-face meeting with patient#3's wife in his office. He stated patient #3's wife entered Administration requesting to speak to someone in charge, she was directed to him by S17Secretary/Receptionist. The patient's wife had questions she needed answers to concern the death, and treatment of patient #3 while he was in the hospital. She voiced being unhappy with the care and services especially delayed in transfer to hospital "A", SCD hose ordered (patient never received), and the staff not giving the patient a bath during the length of his hospital stay. S13MD CMO/VPMA stated he informed the patient's wife he would have all of her complaints looked into and someone would be getting back to her at a later date. According to S13MD CMO/VPMA the care complaints were directed to nursing services and he discussed the course of treatment with the physicians (S12MD Hospitalist, Nurse Practitioner, and S14MD Hospitalist). He further stated he turned the complaint over to S10Risk/Safety Management to further look into the complaints. When ask S13MD CMO/VPMA stated this was the only contact which he had with the patient's wife, recalling a scheduled meeting in which he was either ill or out for personal reasons. According to S13MD CMO/VPMA during his absence S10Risk & Safety Management was the go to person. S13MD CMO/VPMA to the best that he could recall he was not should if a grievance had been generated and or if a written response had been provided to patient's #3's wife.
S13MD CMO/VPMA reported he had several meetings with S14MD Hospitalist and Nurse Practitioner which included chart review and reviewing the care of the patient. According to S13MD CMO/VPMA was not able to recall the dates, e-mails read to S13MD CMO/VPMA by Surveyor at which time he identified the dates of 5/8,5/20th,&5/21/13. He further confirmed that S10Risk/Safety Management was present at each meeting. He could not recall any documentation that he had of these meetings. He concluded that a transfer was not an urgent or emergent need for the patient, and patient #3 and wife wanted to be transferred to hospital "A" because of the personal relationship with the Liver Specialist based on the patient electronic medical record review and interview with S14MD Hospitalist and Nurse Practitioner.

In an interview on 7/31/13 at 11:25 a.m. with S10 Risk/Safety Manager, revealed that the patient's In wife made an initial complaint on 4/15/13 and on 6/10/13 and there was no notice sent to her within 7 days informing her of any progress, and or resolution.. On 6/10/13 she concluded that no written notice was given to the patient wife. After a review of the hospital complaint and grievance resolution policy she confirmed the policy was not followed.


Review of the hospital's policy titled; Complaint and Grievance Resolution, presented as the current hospital policy approved by the hospital board, revealed in part, "...To assure that all grievances are addressed in a timely manner and to enable the hospital to track and trend opportunities for improvement, all complaints as described above should be: 1. reported to the appropriate Manager/Director or Hospital Agent. 2. The Manager, Director or other Hospital Agent will investigate immediately, all situation in which patients are said to be endangered, such as Associates abusing or neglecting patients. All other grievance will be investigated as soon as possible. The Hospital agent will keep the patient or patient's representative informed of all actions directed at resolving the complaint. Contact with the patient or the patient's representative should be made within 24 hours.....4. The above member of the hospital administrative team will provide written follow-up to patient or patient's representative as soon as possible (There should be a written response of acknowledgement/progress or resolution within 7 days)...6. Final Resolution of the grievance includes providing the patient with:
a. Written notice of the review and the hospital agent or contact person
b. Steps taken on behalf of the patient to investigate
c. The outcome of the investigation
d. Any decisions made that the patient or patient's representative should be informed of
e. The results of the grievance process
f. The date of completion..."

Based on record review and interview the hospital failed to ensure a written response to grievances were provided in a reasonable time frame to the patients' families for 2 ( Patient #3 and Patient #5) out of 5 (Patient #3, Patient #5, Patient #R1, Patient #R2, Patient #R3) grievances reviewed.
Findings:
Patient #5
Review of the medical record for Patient #5 revealed he was a 64 year old gentleman who was admitted on 12/11/12 with a history of falls, mental retardation, altered mental status, and a questionable seizure. He was discharged from the hospital with home health services on 12/24/12.
A phone interview was conducted on 7/31/13 at 10:05 a.m. with S13Chief Medical Officer/Vice President of Medical Affairs (CMO/VPMA). He reported that he had never spoken to the family of Patient #5. He went on to report S16Administrative Assistant spoke to the family and wrote down the family's concern about their brother's care. S16Administrative Assistant gave the information to him and he forwarded the information by email to S18Director of Emergency Services.
An interview was conducted with S16Adminstrative Assistant on 7/31/13 at 10:15 a.m. She stated the brother and sister-in-law to Patient #5 came by the administrative offices on 6/25/13 and they voiced a concern about Patient #5's care while he was in the emergency room. No one was available at the time, so she took down the information and emailed their concerns to S13Chief Medical Officer/VPMA. S16Administrative Assistant reported the family stated that their brother was given a drug in the emergency room and after he was administered the drug, he lost control of all his bodily functions and never regained them back. They went on to report he was discharged home and readmitted again to the hospital within a short time period, then discharged again from the hospital and sent to a nursing home and later died in a long term care facility. S16Administrative Assistant further reported on 7/25/13, she thought the sister-in-law came back to the hospital to the administrative offices and spoke to S17Secretary/Receptionist.
An interview was conducted with S17Secretary/Receptionist on 7/31/13 at 10:30 a.m. She reported she wasn't sure of the date, but in the last week, the sister-in-law to Patient #5 came back to the hospital and spoke to her about not hearing back from anyone related to her concerns she reported to the hospital last month. S17Secretary/Receptionist reported she thought someone got back to the family that day and set up a meeting to speak with them this week.
An interview was conducted with S19Director of Nursing Administration on 7/30/13 at 11:45 a.m. He reported in the last month he was appointed to be over the hospital's complaint/grievance process because there had been some changes in personnel. He reported, while he was on vacation on 6/25/13, the brother and sister of Patient #5 came into the hospital and voiced concerns about the care their brother received while in the emergency room. He thought S13Chief Medical Officer/VPMA spoke to the family and emailed the information to S18Director of Emergency Room to investigate the family's concerns. S19Director of Nursing Administration reported S18Director of Emergency Services attempted to make phone contact with the family and was unable to make contact with family. He further reported the family came back to the hospital last week to follow-up with the family's concerns and a meeting had been set up with the family in the next few days to discuss their concerns.
An interview was conducted with S18Director of Emergency Services on 7/30/13 at 12:10 p.m. He reported S13Chief Medical Officer/VPMA had routed, by email ,the family's concerns related to the care their brother received in the emergency room. He stated he made numerous attempts to call the family, but was unable to get in touch with the family. He went on to state, there was no answering machine at the home so he was unable to leave a message for the family to return his call. He reported Patient #5 lived with his brother before his hospital stay and after his hospital admissions in December 2012 was placed in a nursing home and then a Long Term Care Facility, where he later died. Patient # 5's brother and sister-in-law were concerned that the Ativan that was administered in the emergency room caused their brother to be unable to take care of his self anymore. He stated he reviewed the medical record and was comfortable that appropriate care was administered to the patient. He reported he realized a letter should have been sent to the family within 7 days and was not.
Review of the hospital's policy titled; Complaint and Grievance Resolution, presented as the current hospital policy approved by the hospital board, revealed in part, "...To assure that all grievances are addressed in a timely manner and to enable the hospital to track and trend opportunities for improvement, all complaints as described above should be: 1. reported to the appropriate Manager/Director or Hospital Agent. 2. The Manager, Director or other Hospital Agent will investigate immediately, all situation in which patients are said to be endangered, such as Associates abusing or neglecting patients. All other grievance will be investigated as soon as possible. The Hospital agent will keep the patient or patient's representative informed of all actions directed at resolving the complaint. Contact with the patient or the patient's representative should be made within 24 hours.....4. The above member of the hospital administrative team will provide written follow-up to patient or patient's representative as soon as possible (There should be a written response of acknowledgement/progress or resolution within 7 days)..."

Patient #3

Review of the closed record for patient #3 reflected a 47 year male admitted to the hospital on 3/14/13 with the diagnoses : Shortness of Breath, Cirrhosis of Liver, Pulmonary Embolism/Infarct, Ascites, Thrombocytopenia, Chronic Kidney Disease Stage IV(Severe), Acute Renal Failure Unspecified, Obstruction of Bile Duct, Polycystic Kidney Disease, Long Term(Current) use of Antiplatelet/Antithrombotic, Respiratory Abnormal Nec, Long-term(Current) use of steroids, Hyperlipidemia, Hyperpkalemia, Esophageal Reflux, and Iatrogenic Hypotension and was discharged by virtue of death on 3/22/13.

Interview on 7/30/13 at 3:30 p.m. with S10Risk/Safety Management revealed she recalled having 2 face-face conversation/meeting (5/20/13 & 6/10/13) and 3 telephone conversations( not certain of the exact dates) with patient #3's wife after his death (3/22/13). She stated that she was unable to recall if she had ever contact the patient's wife to only give her updates on the ongoing investigation and findings. When asked if she had any documentation of the meetings and telephone calls she replied "no". She confimed the e-mails were all that she had indicating that efforts were being made to find answers to the questions which the patient's wife had requested (4/15/13).
S 10 Risk/Safety Management confirmed that meetings were held as scheduled on the e-mails for record review, and discussion she was not able to recall if any line staff (CNAs, Floor Nurses) had been interview and or involved in the investigation. When ask if they should have her reply was "yes." According to S10Risk/Safety Management the patient's wife was only extended an invitation to the meeting on 6/10/13 for the purpose of providing the patient's wife with an explanation of the transfer process, transfer as it related to the patient, and care of the patient during the hospital. She stated in attendance were S10Risk/Safety Management, S14MD Hospitalist, S15Case Management, Nurse Practitioner, and Regional Vice President of Clinical Operations, S13MD CMO/VPMA did not attend (out sick/personal). According to S10Risk/Safety Management, S14MD Hospitalist went over care of the patient, explained the transfer process, treatment rendered during the course of the patient's hospital stay, and transfer as it related to the patient. She also informed the patient's wife that the team had concluded the SCD hose were ordered and not placed on the patient, and the transfer was not necessary it was not urgent nor an emergency.
According to S10Risk/Safety Manager there was a break between the conclusion of the investigation and the meeting with the patient's wife due to scheduling conflict of S14MD Hospitalist and S13MD MO/VPMA vacations therefore 6/10/13 was the earliest date that both doctors would be available. S10Risk/Safety Manager stated she telephoned the patient's wife, who at this time informed her that she was upset by the length of time it was taking to set-up a meeting. She stated she offered the patient's wife to meet at an earlier date however both doctors would not be present due to their schedule. According to S10Risk/Safety Manager the patient's wife agreed to wait until both doctors could be present.

A telephone interview was conducted on 7/31/13 at 10:15 a.m. with S13MD MO/VPMA confirming that the notes dated 4/15/13 were notes written by him during a face-face meeting with patient#3's wife in his office. He stated patient #3's wife entered Administration requesting to speak to someone in charge, she was directed to him by S17Secretary/Receptionist. The patient's wife had questions she needed answers to concern the death, and treatment of patient #3 while he was in the hospital. She voiced being unhappy with the care and services especially delayed in transfer to hospital "A", SCD hose ordered (patient never received), and the staff not giving the patient a bath during the length of his hospital stay. S13MD CMO/VPMA stated he informed the patient's wife he would have all of her complaints looked into and someone would be getting back to her at a later date. According to S13MD CMO/VPMA the care complaints were directed to nursing services and he discussed the course of treatment with the physicians (S12MD Hospitalist, NP, and S14MD Hospitalist). He further stated he turned the complaint over to S10Risk/Safety Management to further look into the complaints. When ask S13MD CMO/VPMA stated this was the only contact which he had with the patient's wife, recalling a scheduled meeting in which he was either ill or out for personal reasons. According to S13MD CMO/VPMA during his absence S10Risk & Safety Management was the go to person. S13MD CMO/VPMA to the best that he could recall he was not should if a grievance had been generated and or if a written response had been provided to patient's #3's wife.
S13MD CMO/VPMA reported he had several meetings with S14MD Hospitalist and Nurse Practitioner which included chart review and reviewing the care of the patient. According to S13MD CMO/VPMA was not able to recall the dates, e-mails read to S13MD CMO/VPMA by Surveyor at which time he identified the dates of 5/8,5/20th,&5/21/13. He further confirmed that S10Risk/Safety Management was present at each meeting. He could not recall any documentation that he had of these meetings. He concluded that a transfer was not an urgent or emergent need for the patient, and patient #3 and wife wanted to be transferred to hospital "A" because of the personal relationship with the Liver Specialist based on the patient electronic medical record review and interview with S14MD Hospitalist and Nurse Practitioner.

In an interview on 7/31/13 at 11:25 a.m. with S10 Risk/Safety Manager, revealed that the patient's In wife made an initial complaint on 4/15/13 and on 6/10/13 and there was no notice sent to her within 7 days informing her of any progress, and or resolution.. On 6/10/13 she concluded that no written notice was given to the patient wife. After a review of the hospital complaint and grievance resolution policy she confirmed the policy was not followed.

Based on the hospital's policy/procedure for Grievance Procedure and interview the hospital failed to ensure that a patient's family who reported a grievance was provided a written notice of the hospital's decision that contained the name of the hospital contact person, steps taken on behalf of the patient (#3) to investigate, outcome of the investigation, result of the grievance process, and the date completed for 1(#3) of 5 grievances reviewed. The hospital failed to identify a patient's (#3) representative complaints as a grievance. Findings:

Review of the grievance logs revealed no grievance documented for patient #3.

Review of a document presented by S10Risk/Safety Management on 7/30/13 at 3:30 p.m. which she identified as notes taken by S13MD CMO/VPMA on 4/15/13 during an interview with patient#3's wife, revealed a hand written document. The document had a date of 4/15/13, patient#3's name, patient #3's wife's name and contact #, and the following questions listed:
1) Compression device never applied or ordered?
2) Nebulizer ordered first time before death?
3) No bath x 8 days by staff
4) Transfer delayed 24 hours -her biggest concern
5) Monitor strips

Review of e-mails presented by S10Risk/Safety Management on 7/30/13 at 3:30 p.m. which she defied as scheduled meetings which were set-up by her to help find answers to the questions which the patient's wife had requested.
Review of the e-mails revealed the staff held meetings on the following dates:
1) S13MD CMO/VPMA first meeting with the patient's wife 4/15/13. (Notes)
2) Meeting on 5/8/13 (subject patient #3 )review with required attendees of S13MD CMO/VPMA, S15Case Management Director, S7Unit Coordinator 3N, and S13MD CMO/VPMA's secretary.
3) Meeting on 5/20/13 (no subject) with S14MD Hospitalist, and Nurse Practitioner.
4) Meeting on 5/21/13 chart review with S14MD Hospitalist, and Nurse Practitioner.
5) Meeting on 6/10/13 subject patient #3's wife -required attendees S10Risk/Safety Manager, S13MD CMO/VPMA, S15Case Management, and S16Adm.Assist.
Further review of the e-mails revealed on 6/10/13 the patient's wife was included as the subject of the meeting.

Interview on 7/30/13 at 3:30 p.m. with S10Risk/Safety Management revealed she recalled having 2 face-face conversation/meeting (5/20/13 & 6/10/13) and 3 telephone conversations( not certain of the exact dates) with patient #3's wife after his death (3/22/13). She stated that she was unable to recall if she had ever contact the patient's wife to only give her updates on the ongoing investigation and findings. When asked if she had any documentation of the meetings and telephone calls she replied "no". She confirmed the e-mails were all that she had indicating that efforts were being made to find answers to the questions which the patient's wife had requested (4/15/13).
S10Risk/Safety Management confirmed that meetings were held as scheduled on the e-mails for record review, and discussion she was not able to recall if any line staff (CNAs, Floor Nurses) had been interview and or involved in the investigation. When ask if they should have her reply was "yes." According to S10Risk/Safety Management the patient's wife was only extended an invitation to the meeting on 6/10/13 for the purpose of providing the patient's wife with an explanation of the transfer process, transfer as it related to the patient, and care of the patient during the hospital. She stated in attendance were S10Risk/Safety Management, S14MD Hospitalist, S15Case Management, Nurse Practitioner, and Regional Vice President of Clinical Operations, S13MD CMO/VPMA did not attend (out sick/personal). According to S10Risk/Safety Management, S14MD Hospitalist went over care of the patient, explained the transfer process, treatment rendered during the course of the patient's hospital stay, and transfer as it related to the patient. She also informed the patient's wife that the team had concluded the SCD hose were ordered and not placed on the patient, and the transfer was not necessary it was not urgent nor an emergency.

An interview on 7/31/13 at 11:25 a.m. with S10Risk/Safety Manager, revealed a complaint was made on 5/15/13 by patient #3's wife and on 6/10/13 a meeting was held and patient #3's wife was present. According to S10Risk/Safety Management the hospital had concluded the investigation and no written notification of outcome/resolution was given to the patient's wife. S10Risk/Safety Management stated the patient's wife was not given any written notice of the contact person, conclusion, findings, and date of completion of the complaint. When ask she stated that the patient's wife should have received a written resolution from her informing her of the findings, conclusions, results and date of completion instead she (S10Risk/Safety Management) informed her verbally. She further confirmed that the hospital's complaint and grievance resolution policy was not followed for patient #3.

Review of the policy and procedure, titled Complaint and Grievance Resolution, revealed in part,"...6. Final Resolution of the grievance includes providing the patient with:
a. Written notice of the review and the hospital agent or contact person
b. Steps taken on behalf of the patient to investigate
c. The outcome of the investigation
d. Any decisions made that the patient or patient's representative should be informed of
e. The results of the grievance process
f. The date of completion..."

Based on record review, observation, and interviews the hospital failed to ensure the nursing staff followed the nursing care plan for each patient.

1. The nursing staff failed to implement a patient's physician's order for daily weights for 3 out of 3 patients ( Patient # 1, #2 and #3) reviewed for implementation of a daily weight physician's order out of a sample of 5 patients (Patient #1, #2, #3, #4, and #5).

2. The nursing staff failed to implement a patient's physician's order for anti-embolism compression device for 2 out of 2 patients (Patient #1 and Patient #3) reviewed for implementation of a physician's order for anti-embolism compression device out of a sample of 5 patients (Patient #1, #2, #3, #4, and #5).

Findings:

1. Daily Weights

Patient #1
Review of the medical record for Patient #1 revealed he was an 88 year old male who was admitted to the hospital for renal failure, heart failure, and hyperkalemia.
Review of the History and Physical dated 7/20/13 revealed he was admitted for diuresis with IV (intravenous) Lasix, chronic kidney disease state II, with some worsening from previous baseline.
Review of the Patient Order Summary dated 7/20/13 revealed an order for weights per unit standard.
Review of the patient's Intake and Output sheet dated 7/19/13 through 7/29/13 revealed only one weight was documented. The weight was an estimated weight of 250 lbs. (pounds) on 7/19/13.
An interview was conducted with S2Nurse Manager on 7/29/13 at 2:15 p.m. She revealed Patient #1's weight should not have been estimated, he should had been weighed and he should have been weighed daily. She confirmed there was no evidence the patient had been weighed during his current hospital stay.
Patient #2
Review of the medical record for Patient #2 revealed the patient was a 69 year old male with complaints of shortness of breath and newly diagnosed congestive heart failure. He was admitted to the hospital on 7/17/13.
Review of the Patient Order Summary dated 7/17/13 and timed 0434 (4:34 a.m.) revealed an order for patient weight per unit standard. Further review of the Patient Order Summary revealed another order for patient weight per unit standard on 7/17/13 at 0826 (8:26 a.m.).A third physician order for daily weights was written on 7/17/13 at 0836 (8:36 a.m.).
Review of Intake and Output Sheet for Patient #2 revealed one weight was documented on 7/17/13. No other weights were documented from 7/18/13 to 07/29/13.
An interview was conducted with S2Nurse Manager on 7/29/13 at 2 p.m. She stated the unit standard for weights were for the nurse techs, on the night shifts, were to perform daily weights. She confirmed there was only one weight documented throughout the electronic medical chart and paper chart on Patient #2 from 7/17/13 until 7/29/13.
2. Anti-Embolism Compress Device

Patient #1
Review of the medical record for Patient #1 revealed he was an 88 year old male who was admitted to the hospital for renal failure, heart failure, and hyperkalemia.
Review of the History and Physical dated 7/20/13 revealed he was admitted for diuresis with IV(intravenous) Lasix , chronic kidney disease state II, with some worsening from previous baseline.
Review of the Patient Order Summary revealed an order dated 7/26/13 at 11:10 a.m. for Anti-Embolism Compress Device.
An interview was conducted with S2Nurse Manager on 7/29/13 at 2:20 p.m. She reported with review of the computerized charting, she could not tell if the order for the anti-embolism compress device was done.
An observation was made on 7/29/13 at 2:30 p.m. with S2Nurse Manager of the patient in the bed with heel protectors on and no anti-embolism compress device on the patient.
Another interview was conducted with S2Nurse Manager on 7/29/13 at 3:30 p.m. She reported there was no documentation that the patient's nurses clarified the order with the physician or notified the physician the patient did not have on an anti-embolism compress device.
An interview was conducted with S1 Regional Compliance Director on 7/29/13 at 3:30 p.m. She reported it was an unwritten policy that the nurses are to do 24 chart checks to make sure all physician orders are carried out.
Another interview was conducted with S1Regional Compliance Director on 7/30/13 at 8:15 a.m. She stated in nursing orientation 24 hours chart checks are taught. S1Regional Compliance Director provided documentation where the 24 hour chart checks were performed on Patient #1's and Patient #2's chart during the patient's hospital stay, but the omitted orders were not identified.
1. Daily weights
Patient #3
Review of the closed electronic record for patient #3 reflected a 47 year male admitted to the hospital on 3/14/13 with the diagnoses : Shortness of Breath, Cirrhosis of Liver NOS, Pulmonary Embolism/Infarct, Ascites, Thrombocytopenia, Chronic Kidney Disease Stage IV(Severe), Acute Renal Failure Unspecified, Obstruction of Bile Duct, Polycystic Kidney Disease, Long Term(Current) use of Antiplatelet/Antithrombotic, Respiratory Abnormal Nec, Long-term(Current) use of steroids, Hyperlipidemia, Hyperpotassemia, Esophageal Reflux, and Iatrogenic Hypotension and was discharged by virtue of death on 3/22/13.

Review of the history & physical for patient #3 revealed he was admitted with SOB (shortness of breath), Cirrhosis of the liver with ascites

Review of the Patient Order Summary reflected an order dated 3/14/14 at 11:56 p.m. revealed an order for patient weight daily per unit standards.
Review of the patient's I&O(intake & output) flow sheet revealed there were no documented weights for the dates of: 3/16, 3/18 ,3/20 ,3/21, & 3/22/13.
Interview on 7/30/13 at with S7Unit Coordinator 3N confirmed after reviewing the I&O (intake & output) flow sheet, and nurses notes there were no weights recorded for the dates of 3/16, 3/18, 3/20, 3/21, 3/22/13 and should have been.
2. Anti-embolism Compress Device
Patient #3
Review of the closed electronic record for patient #3 reflected a 47 year male admitted to the hospital on 3/14/13 with the diagnoses : Shortness of Breath, Cirrhosis of Liver NOS, Pulmonary Embolism/Infarct, Ascites, Thrombocytopenia, Chronic Kidney Disease Stage IV(Severe), Acute Renal Failure Unspecified, Obstruction of Bile Duct, Polycystic Kidney Disease, Long Term(Current) use of Antiplatelet/Antithrombotic, Long-term(Current) use of steroids, Hyperlipidemia, Hyperpotassemia, Esophageal Reflux, and Iatrogenic Hypotension and was discharged by virtue of death on 3/22/13.

Review of the history & physical for patient #3 revealed he was admitted with SOB (shortness of breath), Cirrhosis of the liver with ascites

Review of the Patient Order Summary reflected an order dated 3/14/14 at 11:56 p.m. for anti-embolism compress device.
Review of the nurses notes for the dates of 3/14-3/22/13 reflected no documentation of patient #3 having anti-embolism compression hose.
Telephone interview on 7/30/13 at 1:37 p.m. with S6RN revealed that on the date of 3/22/13 patient #3 had no anti-embolism compression hose on.
Telephone interview on 7/30/13 at 4:16 p.m. with S11 CNA revealed that patient #3 was up ambulating in his room on the morning of 3/22/13 and he did not have on anti-embolism compression hose nor did she recall seeing a machine in the room.
An interview on 7/30/13 at 4:25 p.m. with S7Unit Coordinator 3N confirmed after reviewing the patient order summary an order for Anti-embolism compression hose were order upon admission. She stated that the ordering physician did not specify the type of anti-embolism hose she wanted therefore the nurses was not certain. After reviewing the nurses notes and on the patient order summary there was no documentation an or an order of clarification for the anti-embolism hose. According to S7Unit Coordinator 3N the nurses the nurse who carried out the admitting orders should have clarified the order, it also should have been discovered during the 24 hour chart check by the night shift.

Based on record review and interview the hospital failed to ensure a patient was evaluated for the need for discharge planning for post hospital services for 1 (Patient #1) out 5 patients (Patient #1, #2, #3, #4, and #5) reviewed for discharge planning services.

Findings:

Review of the medical record for Patient #1 revealed he was an 88 year old male who was admitted to the hospital for renal failure, heart failure, and hyperkalemia.
Review of the History and Physical dated 7/20/13 revealed he was admitted for diuresis with IV (intravenous) Lasix and chronic kidney disease state II, with some worsening from previous baseline.
Review of the Admission Assessment dated 7/20/13 at 19:30 (7:30 p.m.) revealed he was admitted from a nursing home.
Review of the Discharge Planning evaluation revealed no documentation of prior living arrangements, support resources, or probable disposition or services needed at time of discharge. The evaluation was blank and not filled out by the admitting nurse as per the hospital policy.
An interview was conducted with S3Case Manager on 7/29/13 at 1:05 p.m. She stated on the telemetry unit, there is a case manager (herself) and a social worker that assists the patients with their discharge needs. When questioned if a discharge needs assessments was performed on Patient #1, she reported there was no evidence in the paper chart or in the electronic chart that anyone had done an evaluation on the patient. She went on to state there was no evidence that the social worker or herself had spoken to the patient or his family about his discharge plans.
An interview was conducted with S4Social Worker on 7/29/13 at 1:30 p.m. She reported she was the social worker on the telemetry unit and she and S3Case Manager saw all the patients on the telemetry unit. When questioned about Patient #1, she stated she had not seen him either, but it looked like he was being discharge today to go back to the nursing home. She went on to report the patient must have been overlooked and she could find no evidence of anyone assessing his discharge needs.
An interview was conducted with S15Director of Case Management on 7/29/13 at 2 p.m. She confirmed there was no evidence that the patient's discharges needs were assessed. She went on to report that the admitting nurse should had assessed the patient's discharge needs and then if the patient was considered high risk, the case manager would had assessed the patient by the next business day. She stated the patient would have been considered high risk due to his age and should have been assessed.
Review of the policy titled, Discharge Planning, revealed in part, "...All patients who enter the system will have a preliminary screening process by the admitting nurse. The screening mechanism is vital to identify the appropriate team members who may further assess the patient...Procedure: A. The admissions case manager acts as a liaison in the proper placement of the patient to facilitate appropriate, cost effective, quality care. The admitting nurse will screen each patient admitted to the hospital for discharge needs. The admitting nurse completes an initial assessment screen in PCS (Patient Care System in Meditech). This mechanism identifies those patients that need a Social Work or Case Management evaluation."
Review of the policy titled, Social Function Screen/High Risk Social Discharge Planning Policy, revealed in part, "....I. A high risk social screen will be completed on patients who enter the hospital. The screen will be completed by the admitting RN, as part of the initial nursing assessment, within 8 hours of admission. The screening mechanism is vital to identify social factors which may impact the patient's care and discharge. ..B. When the social screen is completed and indicates a risk, a clinical notification is sent via printer to the Case Management Department. This sheet indicates at risk patients...D. A social work assessment will be completed on all patients deemed high risk. This assessment will be completed by a Social Worker within 24 hours of admission..."