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Based on record review (patient record and hospital policy)and staff interviews, the hospital failed to ensure that a process was in place to ensure that all complaints and/or grievances were processed in a timely and consistent manner to ensure prompt resolution. This was evidenced by the hospital's failure to identify a grievance and failure to implement the grievance process for 1 of 1 patients (Patient #4) reviewed for the implementation of the grievance process out of a total sample of 7 patients. Findings:

The Medication Record for Patient #4 was reviewed.
Review of the "Operative Note" dated 01/29/10 revealed in part, "Procedures Performed; Laparoscopy with open myomectomy."
Documentation revealed Percocet was administered the day of surgery (order was for Post operative day one)) at 2150. (9:50pm) and Zofran 4 mg IVP was administered for nausea on 01/29/10 at 17:30 (5:30pm) and 2340 (11:40pm).
Further review of the Electronic Nurses ' Notes revealed in part, " 01/30/10 0600 (6am) pt been nauseated all night." Documentation on the Physician ' s Order Form dated 01/30/10 0650 (6:50am) revealed an order for Phenergan 25 mg IM Q 4hs PRN nausea.
There was no further documentation in the Medication Record Patient #4 was administered anti-nausea medication after 01/29/10 at 11:40pm until 01/30/10 at 8am when she was administered the Phenergan 25 mg IM.

S7, RN and S8, RN, Director of Telemetry were interviewed face to face on 03/15/10 at 1:45pm. S7, indicated he had been an RN for one year on the 2nd floor Telemetry Unit and had been assigned from 7p to 7a to the care of Patient #4 during her stay on the Telemetry Unit. S7 and S8 reviewed the record for Patient #4. S7 indicated he had administered Zofran to Patient #4 on 03/15/10 at 2340. (11:40pm) Further he had documented at 6am Patient #4 had been nauseated all night and he had notified the physician and got an order for Phenergan 25 mg at 6:50am. Further he had not administered the Phenergan but had passed the information on to the day nurse during report.

S9, LPN was interviewed face to face on 03/15/10 at 2:20pm. S9 reviewed the record for Patient #4. S9 indicated she had taken report from S7 on 01/30/10 at about 6:45am. Further S7 had reported Patient #4 had complained of nausea and had indicated the Zofran had not been effective. Further she made rounds after report and Patient #4 complained of nausea and she administered the Phenergan at 8am.

S13, RN Nursing Supervisor was interviewed face to face on 3/16/10 at 9:40 a.m. S13 indicated she had worked on 01/30/10 and was approached by Patient #4's husband in the hospital's lobby. S13 reported Patient #4's husband was upset about what he reported to be a delay in treating his wife's nausea. S13 indicated Patient #4's husband reported it took too long to get an order and treat her nausea. Further she had asked if the Patient's nausea had been treated and Patient #4's husband reported it had been treated. Further she had not documented his complaints regarding Patient #4's care. S13 indicated Patient #4's husband voiced no additional complaints to her (S13) other than the delay in treating Patient #4's nausea. Further S13 indicated she informed Patient #4's husband to contact her should he have any more complaints or concerns. S13 reported she went to the floor, looked at Patient #4's MAR to ensure she had received her medication for nausea and discussed Patient #4 ' s husband ' s concern with Patient #4's nurse. S13 reported the nurse informed her the patient's nausea had been treated. S13 reported she (S13) informed the operational coordinator and took no further action in relation to the complaint reported by Patient #4's husband.

S14, In-House Post Coordinator was interviewed on 3/16/10 at 10:05 a.m. S14 indicated she made a routine post discharge follow up call to Patient #4 on 2/02/10 to discuss her feelings about the care and services that she received during her hospitalization. S14 indicated Patient
#4 reported she was not satisfied with the care she had received during her hospitalization. S14 indicated Patient #4 informed her she (Patient #4) woke up from surgery screaming in pain and someone injected something in her IV that did nothing to control her pain. S14 indicated Patient #4 reported she (Patient #4) was then taken to her room and she was screaming in pain all the way. S14 indicated Patient #14 reported she had been in her room for 30 minutes before any pain medication was given. S14 indicated Patient #4 reported she was given Demerol for the pain which did work. S14 indicated Patient #4 reported a nurse (S7) allowed her to be nauseated all night. S14 indicated Patient #4 reported a new nurse came in at 5:00 a.m. and reported she was going to get Phenergan for the nausea but never came back. S14 indicated she was not given anything for nausea until after 8:00 a.m. and she was dehydrated by this time. S14 reported Patient #4 told her she (Patient #4) wanted this dealt with and she expected a follow up call. S14 reported she informed S8, Director of Telemetry,of Patient #4's complaints.

The Nurse Manager of Telemetry (S8) was interviewed on 3/16/10 at 10:55 a.m. S8 indicated she was informed about the complaints voiced by Patient #4 regarding her dissatisfaction with care and services provided during her hospitalization. S8 reported she contacted Patient #4 by phone on 2/03/10 at 9:20 a.m. S8 confirmed Patient #4 reported she was unhappy with the care and services provided during her hospitalization. S8 reported Patient #4 had multiple complaints relating to her care on the telemetry unit, in the PACU and with her physician. S8 reported Patient #4 told her she had been having nightmares because of the neglect of attention she received when she woke up screaming in pain. S8 indicated she did not inform the Patient Relations Specialist of Patient #4's complaint. S8 indicated she did not follow the hospital's grievance process in regards to Patient #4's complaint.

S2, Director of Surgical Services was interviewed face to face on 03/15/10 at 1:25pm. S2 indicated she had been informed by S14, In-house Post Coordinator for 2nd floor regarding a complaint from Patient #4. Further S2 called Patient #4 to see what had happened and Patient #4 indicated her pain had not been controlled during her stay in PACU. S2 stated she apologized and she thought Patient #4 was satisfied and that the issue had been resolved. Further she had not documented Patient #4's issues or referred the complaint to the Director of Quality.

The hospital's grievance log titled "List of Grievances" for January 1, 2010 through March 15, 2010 was reviewed. This review revealed Patient #4 was not included on the hospital's " List of Grievances.".

The hospital's policy/procedure titled "Patient Complaint & Grievance (to include Patient Privacy Violations)" was reviewed. The policy/procedure documents "It is the purpose of this policy to establish a process for prompt resolution of patient/visitor complaints and grievances, and for informing patients whom to contact to file grievances or suspected HIPPA privacy and security violations. It is also to be used for reporting and resolving claims of harassment and/or discrimination that violate Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act as well as violations of other Federal or state laws or regulations. In addition, the policy outlines the structured mechanism used in providing timely, reasonable and consistent responses.

This policy applies to the patients, family members and visitors of Ochsner Medical Center- Baton Rouge." The policy/procedure documents "a patient grievance is a written or verbal complaint (when the verbal complaint about the 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's care, abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations. Patient grievances would also include situations where patients or the patient's representative call or write to the hospital about concerns related to care and services, who were not able to resolve the concerns during their stay. Additionally, whenever the patient or the patient's representative requests their complaint be handled as a formal grievance or when the patient requests a response from the organization, then the complaint is considered a grievance." The policy/procedure documents "Any grievance or complaint that involves situations or practices that place any patient in immediate danger will be addressed immediately. All grievances will be addressed as quickly as possible. If unable to resolve within 7 days from receipt, a written notice of acknowledgement, including an estimated time for the final response, will be sent to the patient or their representative. A formal written response should be sent to the patient within 30 days of receipt of the grievance."

S4, Director of Quality was interviewed on 3/16/10 at 9:50 a.m. S4 reviewed the hospital's policy/procedure titled "Patient Complaint & Grievance (to include Patient Privacy Violations)" and indicated there were holes in how the hospital had been handling grievances reported by patients and/or patient representatives. S4 indicated all grievances should be routed to the hospital's Patient Relations Specialist to ensure the hospital is in compliance with all components of the grievance process. S4 indicated she had reviewed Patient #4's case and felt Patient #4's complaint should have been handled as a grievance but this was not done. Further S4 indicated Patient #4 should have received written notification by the hospital informing her (Patient #4) of all components required in the grievance process. S4 also reported Patient #4 should have been listed on the hospital's "List of Grievances" . S4 indicated she felt Patient #4's complaint was not handled as a grievance because of a breakdown in the communication between the clinical staff who spoke with Patient #4 and the Patient Relations Specialist. S4 reported she is in the process of implementing measures to improve the hospital's grievance process in an effort to ensure that future cases are routed and handled appropriately.

Based on record review and interview, the hospital failed to ensure the nursing staff followed the plan of care for each patient by failing to follow a physician's order for the removal of an indwelling catheter for 1 of 1 patients with a catheter (Patient #4) out of a total sample of 7 patients. Findings:

The medical record for Patient #4 was reviewed.
Review of the " Operative Note " dated 01/29/10 revealed in part, "Procedures Performed; Laparoscopy with open myomectomy."
Review of the "Discharge Summary" dated 01/31/10 revealed in part, "Discharge Diagnosis: Uterine leiomyoma with myometrial hematoma."
Review of the "Post-OP Day One Protocol" revealed a physician's order dated 01/29/10 1800 (6pm) for "2. Remove indwelling urinary catheter in AM".
Review of the Nurses Notes dated 01/29/10 at 18:00 (6pm) revealed " D/C Foley Cath per MD orders. Further review of the Nurses Notes dated 01/30/10 at 0600 (6am) revealed "pt had foley taken out yes at 1830 (6:30pm) and hasn't voided up to this point. Called Dr. (name of physician) to get order."

S12, LPN was interviewed face to face on 03/16/10 at 9:15am. S12 indicated she usually works on the 5th floor Med/Surg Unit but was transferred to the 2nd floor Telemetry Unit on 01/29/10 and assigned to Patient #4. S12 reviewed the record for Patient #4 and she indicated she had assessed Patient #4 at 14:30pm (2:30pm) when she arrived on the Telemetry Unit 5th floor. Further she had removed Patient #4's indwelling catheter at 1800 (6pm) on 01/29/10 the day of surgery. (Physician's order indicated in am/ Post-Op Day One Protocol)

Based on record review and interview the hospital failed to ensure medications were administered according to physician orders and acceptable standards of practice by failing to ensure medications were administered as per physician's orders for 3 of 7 sampled patients (Patient #4, #5 & #6); to Findings:

Patient #4
Review of the "Operative Note" dated 01/29/10 revealed in part, "Procedures Performed; Laparoscopy with open myomectomy."
Review of the "Discharge Summary" dated 01/31/10 revealed in part, "Discharge Diagnosis: Uterine leiomyoma with myometrial hematoma."
Review of the "Anesthesiology Group Associate Protocols for PACU" revealed orders for the following:
"6. Pain: Fentanyl 25m micrograms (mcg) increments IVP, every 2 minutes, up to 200 micrograms for complaint of pain.
"7. Anxiety: Midazolam (Versed) 0.5 milligrams IVP, every 2 minutes, up to 2 milligrams for complaints of anxiety."
Review of the Post-OP GYN Physician Protocol Orders Day of Surgery Medications, revealed, Ketorolac (Toradol) 30mg IVP in recovery room, then 30mg IV every 6 hrs x 24 hrs. Meperidine (Demerol) 75mg IM every 4 hrs prn pain. Ondansetron (Zofran) 4 mg IVP every 6 hrs prn nausea.
Review of the Post-OP Day One revealed a physician's order dated 01/29/10 for" Oxycodone/Acetaminophen 5/325mg (Percocet-5) every 4 hours prn mild moderate pain"
Review of the "Nursing PACU Record" revealed Patient #4 was admitted to the PACU on 01/29/10 at 12:07pm. Status of Patient #4's administration of medications were as followed.:

12::25pm: Fentanyl 50mcg IV push was administered
12:45pm, Fentanyl 50mcg IV push was administered
12:56pm Fentanyl 50mcg IV push was administered
1:17pm Versed 1 milligram (mg) IV push was administered
2:00pm Versed 1mg IV Push was administered.

Further review of the Physician's Orders revealed no documented evidence of a Physician's Order to increase the dosage of the Fentanyl to 50 micrograms (mcg) or the Versed to 1 milligrams. There was no documented evidence Patient #4 was administered Fentanyl every 2 minutes (as per physician's orders) from 1:50pm to transfer out at 2:18pm (a total of 28 minutes) at which time she verbally indicated her pain scale was 9 (Worst Pain Imaginable at 1:50pm and 5 (Moderate) at 2:15pm.

The Medication Record for Patient #4 was reviewed. Documentation revealed Percocet was administered the day of surgery (order was for post operative day one)) at 2150. (9:50pm)
Further review of the Electronic Nurses' Notes revealed in part, "01/30/10 0600 (6am) pt been nauseated all night. "Documentation on the Physician's Order Form dated 01/30/10 0650 (6:50am) revealed an order for Phenergan 25 mg IM Q 4hs PRN nausea.
There was no further documentation in the Medication Record Patient #4 was administered anti-nausea medication after 01/29/10 at 11:40pm until 01/30/10 at 8am when she was administered the Phenergan 25 mg IM.

S3, Clinical Coordinator PACU and S2, RN Director of Surgical Services were interviewed face to face on 03/15/10 at 1:25pm. S3 indicated she had been the Charge Nurse of PACU for 3 years and Clinical Coordinator since the fall of 2009. S3 reviewed the record for Patient #4. S3 verified there was no Physician's Order to administer Fentanyl 50 mcg instead of the 25mcg as per the physician's order. S3 indicated there was an understanding between the RN and the Anesthesiologist to administer 25 to 50 mcg of Fentanyl and the RN was always in direct communication with the anesthesiologist in regards to pain management. Further S3 indicated the physician's order for Fentanyl did not specify parameters for the dosage. S2, indicated the RN failed to write a verbal order for the administration of the 50mcg of Fentanyl. S3 and S2 reviewed the times the Fentanyl was administered in the PACU and both indicated after review the Fentanyl could have been administered prior to the Patient leaving the PACU and the physician's order to administer Fentanyl 25mcg up to 200mcg every 2 minutes for pain was not followed. Further according to documentation Patient #4 had received a total of 150mcg in
PACU.

S7, RN and S8, RN, Director of Telemetry were interviewed face to face on 03/15/10 at 1:45pm. S7, indicated he had been an RN for one year on the 2nd floor Telemetry Unit and had been assigned from 7p to 7a to the care of Patient #4 during her stay on the Telemetry Unit. S7 and S8 reviewed the record for Patient #4. S7 indicated he had administered Zofran to Patient #4 on 03/15/10 at 2340. (11:40pm) Further he had documented at 6am Patient #4 had been nauseated all night and he had notified the physician and got an order for Phenergan 25 mg at 6:50am. Further he had not administered the Phenergan but had passed the information on to the day nurse during report. Further he had administered the Percocet at 2150 (9:50pm) on the day of surgery which was ordered for Post-Op Day one.

Patient #5:
Medical record review revealed that the patient was admitted to the hospital on 1/29/10. The patient's documented medical diagnoses included Hyperdysmenorrhea, Hydrosalpinx, and Uterine Leiomyoma. Review of the "Anesthesiology Group Associates Protocols for PACU" revealed orders dated 1/29/10 at 6:36 a.m. for "Fentanyl 25 mcg increments IVP, every 2 minutes, up to 100 mcg for complaints of pain. Review of the medical record revealed that 50 mcg of Fentanyl was administered IV push on 1/29/10 at 10:35 a.m. There was no documentation to indicate that the Fentanyl was administered in 25 mcg increments as ordered. S2 (Director of Surgical Services) was interviewed on 3/15/10 at 3:30 p.m. S2 reviewed the medical record of Patient #5 and confirmed that the medical record did not reflect the Fentanyl was administered to Patient #5 in 25 mcg increments as ordered.


Patient #6:
Medical record review revealed that the patient was admitted to the hospital on 3/15/10. The patient's documented medical diagnoses included Hypertension, Diabetes and Chronic Kidney Disease. Review of the record revealed a critical lab value relating to the patient's potassium level being 2.4 (critically low). Review of the "ER initial Orders" revealed orders dated 3/15/10 at 2:45 p.m. for 40 meq of Potassium to be administered IV over 4 hours. Review of the medical record revealed that 20 meq of Potassium was administered IV over 2 hours. There was no documentation to indicate that the 40 meq was administered IV to the patient as ordered. In addition, there was no documentation to indicate a reason why the 40 meq of Potassium was not administered IV as ordered and no documentation to indicate that the physician had been notified that the 40 meq was not administered as ordered. Further review of the medical record revealed that the patient's potassium level remained low during subsequent checks. The patient's potassium level was 2.5 on 3/15/10 at 8:55 p.m. and 2.4 on 3/16/10 at 4:15 a.m. S8 (Nurse Manager of Telemetry) was interviewed on 3/16/10 at 8:40 a.m. S8 reviewed the medical record of Patient #6 and confirmed that the medical record did not reflect that 40 meq of Potassium was administered intravenously to Patient #6 as ordered.

Review of the hospital policy for "Anesthesia Care, Recovery of Patients Following:" presented as the hospital's current policy revealed in part, "14. Assess level of pain and initiate pain management plan, manage post operative nausea and vomiting per physician's orders. 15. Review chart for new physicians orders and implement/complete all post-op orders as written by the physician."

Review of the hospital policy for "Medication Administration" presented as the hospital's current policy revealed in part, "9. Each medication must have a physician's order that states the drug administration times or the time interval between doses. 10. All physician orders for medication should be followed. Any questions or changes should be documented as a verbal order or clarification."