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Based on record review and interviews the hospital failed to review, investigate and resolve a patient's grievance within a reasonable time frame for 2 out 6 grievances reviewed ( #4,#10) Findings:

Patient #4
Patient #4 is a 20 year female with a past medical history of Insulin Dependent Diabetes Mellitus (IDDM) and Obesity. Her previous surgical history included a gastric sleeve, which was performed in September 2010. She was admitted to the hospital on 10/16/10 for nausea and vomiting and transferred to hospital "a" on 10/22/10.

An interview was conducted with S7Unit Manager of Med/Surg unit on 10/25/11 at 1 p.m. She stated on 10/22/10 she was making rounds on her unit and she was talking to the mother of Patient #4. On her previous days rounds the mother had not been with her daughter, so this was the first time she had met the mother of Patient #4. The mother reported she was dissatisfied with the care her daughter had received at the hospital because her daughter was not getting any better. S7Unit Manager went on to report the mother didn't elaborate more, but basically she would be in touch.

Review of the Task System, the complaint central monitoring system the hospital uses to track complaints, revealed the first entry was on 11/19/10 at 0730 (7:30 a.m.) entered per S7Unit director. It stated, "I spoke with the mother of Patient #4 this a.m. in reference to meeting that was set up for today with S1CNO and myself. She said she would not be able to meet due to her daughter was starting therapy and she needed to be with her. I ensured the mother we wanted to meet with her to address any concerns and when things settle down she could call and reschedule the meeting. She said that was fine and she would call back and reschedule."

The second entry entered in the Task System for complaints was made by S8Administrative Assistant. The entry revealed the following letter was sent to the mother of Patient #4. S8 reported at this time, we did not know what her concerns were related to her daughter's care. The letter stated the meeting that was scheduled today with S1CNO and S7Unit Director was canceled. The patient's mother wanted to be with her daughter during her first therapy session. The letter sent to the complaint was dated 11/19/10. Review of the letter revealed in part, " I am sorry we were unable to meet today at 1:00 p.m., but I do understand you wanting to be with your daughter during her therapy. We are looking forward to meeting you and discussing any concerns you may have regarding your daughter's inpatient stay at Lane ...I will be out of the office until December 13, but please feel free to contact S7Unit Director at ..."

On 02/18/11 there was note in the complaint system stating that S1CNO and S7Unit Director had a meeting with the mother of the patient on 02/21/11. S1CNO made a statement in the central complaint system after the meeting with the mother that stated, " Mother of Patient #4 came in today with Patient #4. Mother of Patient #4 presented me and S7 a three page document of her concerns. Her concerns regarding nursing care were; rudeness of triage nurse on 10/16/10; S2 nurse not taking HL (heparin lock) out when it was leaking and hurting and allowed it to remain in place when patient left for Hospital "a" . Her concerns regarding physician S5MD were: She did not think S5MD should have allowed her to be transported to Hospital "a" in private car instead of ambulance. She felt S5MD was not responsive to patients complaints that Phenergan IV was painful and causing her to sleep most of the time. The patient and mother requested that she not be held responsible for copay since she was not satisfied with service. She requested her complaints be addressed with S5MD and that she receive written communication about result of the review. "

The next letter was dated 03/11/11 from S1CNO. Review of the letter revealed in part," After our meeting on February 21, 2011, I wanted to take a moment to assure you that S7Unit Director has addressed your concerns with the involved staff ...All complaints involving physicians are referred to our Medical Executive Committee for review. You can expect a written communication once that review has taken place."

The Medical Executive Committee (MEC) Meeting that the grievance was reviewed was conducted March 3, 2011.

A note was placed in the central complaint system by S11Medical Staff Coordinator on 03/30/11. The entry revealed the MEC reviewed the grievance at the 3/03/11 meeting. "After discussion and further review, it was determined that no further actions are required". A letter was mailed to S5MD giving her the results of the review.

On April 6, 2011 S8Administrative Assistant drafted a letter for the Patient's mother of the results of the investigation. This was over a month after the Medical Executive Committee met to offer their recommendations.

On April 19th there was an entry stating the family never received the letter. S7 obtained a new address for the patient and resent the letter with the date April 19 instead of April 6th on the letter.

An interview was conducted with S8Adminstrative Assistant on 10/25/11 at 2 p.m. She stated if the patient comes into the office she sometimes takes the complaint up front. Normally if she doesn't take the complaint from patient she will type the letter to the patient for the nurse managers. When questioned about Patient #4's complaint, she reported she was not sure how they became aware that the family wanted to meet with S1CNO and S7Unit Manager on 11/19/10, but it must have been a phone call by the family. Once the family cancelled the meeting, S8 reported she sent a letter to the family. At this point she went on to report, the hospital wasn't aware of her issues. She stated S7Unit Manager was in contact with the family by phone. On 02/21/11 a meeting occurred with S1CNO, S7Unit Manager and Patient #4 and her mother. The mother brought the 3 page letter of her concerns to the meeting and gave the letter to S1CNO and S7Unit Manager. She went on to report on 03/11/11 a letter was sent to the family to state the Medical Executive Committee would be reviewing her complaint. When questioned on what was the delay with sending the letter to the family, she stated she did not know. She went on to state on 04/06/11 another letter was sent to the family letting them know the investigation was complete. When questioned why there was a delay with letting the family know the investigation was complete, she stated she was not sure.

Review of the letter sent to the family on 04/06/11 revealed in part that a peer review was conducted and it was determined appropriate care was given and no further action was required and the involved physician was made aware of her concerns.

An internal text in the central complaint system dated 04/19/11 was reviewed and revealed the family did not receive the letter with the results of the investigation and S7Unit Manager obtained a new address and the letter was resent on 04/19/11.

An interview was conducted with S1CNO on 10/25/11 at 2:30 p.m. When questioned about the current system in place for complaints and grievances to be addressed, she reported the complaint would be reviewed and assigned to the manager whose unit was involved in the complaint. S8Adminstrative Assistant would write the letter when the information was put in the central complaint system. When the person investigating the complaint documents it in the system, the system is flagged and brought to S8's attention. Complaints against physicians are reviewed in Medical Executive Committee Meetings, which only meet once a month. With Patient #4's complaint there was a delay in S11Medical Staff Coordinator putting the results of the peer review in the central complaint system.

On 10/26/11 at 9 a.m. an interview was conducted with S11Medical Staff Coordinator. She stated when there are complaints against physicians to be reviewed at Medical Executive Committee; S12Quality Resource Director sends the information to be reviewed to her. The committee meets usually on the first Thursday of the month. She reported she couldn't explain the delay from the meeting on March 3 to when the letter was sent to the family a month later with the results of the peer review. She also reported she recently became aware of the timelines to notified families of the results of their complaints.

Patient #10

Patient #10 was admitted to the hospital on 05/26/11 for short stay for shortness of breath and was discharged on 05/27/11.

Review of the complaint by Patient #10 revealed the following: "Patient #10 commented that when he came to the ER (emergency room) he thought he was having a heart attack, He thought a cardiologist should of been called in. S21MD was assigned to him. He said he didn't see the doctor for almost 24 hours and when he did, he told him that he was paranoid and having post operative issues, but his heart was fine. He stated that he didn't appreciate being told he was paranoid. He also thought that was an unusual long wait before seeing a doctor. He said he had quadruple bypass 04/20/11 and he was having some of the same symptoms that had taken him to the hospital before his surgery."

Review of the central complaint system revealed the hospital became aware of the complaint on 05/30/11. On 06/05/11 S20Emergency Room Director was assigned to investigate the complaint. On 06/17/11 documentation in the central complaint system was made by S12Quality Resource Director indicating an initial letter was never sent to the patient. On 07/13/11 S20Emergency Room Director documented he would send a letter. On 07/19/11 S20 documented in the central complaint system asking S8Administrative Assistant to draft a letter to the family. On 07/21/11 a letter was sent to the family. On 09/15/11 Medical Executive Committee (MEC) met and review the grievance and no recommendations were made. A letter was sent on 09/23/11 to S21MD, the physician the MEC did a peer review on. No documentation was made of a letter being sent to the familiy on the results of the investigation.

An interview was conducted with S3Quality Assurance Director on 10/27/11 at 9:15 a.m. She stated she could find no documentation where a letter was ever sent to the family on the results of the investigation.

Review of the hospital's policy titled Patient Grievances revealed in part, "3. Prompt efforts will be made to resolve grievances...5. The hospital will acknowledge the receipt of the grievance within 7 working days. A written response to a grievance will be attempted to be made in 15 working days. If response time period will be longer, a verbal contact either in person, phone or e-mail will be made prior to the written response with 15 working days."

Based on record review and interviews the hospital failed to identify the excessive length of time grievance were being reviewed, investigated, and resolved by failing to put an action plan in place to evaluate the problem. Findings:

Review of the Quality Assurance Plan revealed no indicators being evaluated related to the length of time grievances were being reviewed, investigation, and resolved.

An interview was conducted with S3Director of Quality Assurance on 10/27/11 at 11 a.m. She reported the hospital had identified the increase in patient complaints entered into the central complaint system, but had not identified the problem with not responding in the appropriate timelines. She went on say no action plan had been put in place to assist in completion of the investigation to a complaint or grievance timely.

Based on record review, observation, and interview the hospital failed to change peripheral intravenous (IV) sites every 72 hours according to hospital policy for 2 out 3 patients reviewed for IV sites ( #4 and #8 ) Findings:

Review of the hospital policy on Intravenous (IV) Site Care revealed the peripheral IV sites were to be changed every 72 hours unless the physician was notified and requested the IV site not to be changed.

Patient #4

Patient #4 is a 20 year female with a past medical history of Insulin Dependent Diabetes Mellitus (IDDM) and Obesity. Her previous surgical history included a gastric sleeve, which was performed in September 2010. She was admitted to the hospital on 10/16/10 for nausea and vomiting and was transferred to hospital "a" on 10/22/10.

An interview was conducted with S7Unit Director the Med/Surg Unit on 10/25/11 at 1 p.m. With review of the medical chart with the surveyor, she reported Patient #4's IV was started in the emergency room on 10/16/10 at 1533 (3:33 p.m.) and the IV was discontinued on 10/20/10 at 0013. (12:13 a.m.). Review of the Nurses' Notes from 10/20/10 at 0013 revealed the IV site was leaking. The IV was restarted in the left arm without problems. S7 reported it is a hospital policy to change a peripheral IV every 72 hours and if the site was not changed for some reason the physician needed to be notified. S7 confirmed Patient #4's IV site was not changed within 72 hours and there was no documentation in the medical record that the physician was notified of the IV site not being changed within 72 hours. The IV site started leaking fluid at 81 hours post insertion time and then the IV site was changed.

Patient # 8

Patient #8 is an 86 year old female admitted for an Urinary Tract Infection on 10/07/11.

An observation was made on 10/26/11 at 1:15 p.m. of the Patient #8 lying in bed with a peripheral IV in her left arm.

An interview was conducted with S15LPN on 10/26/11 at 1:20 p.m. She reported according to the report from the previous nurse, the current peripheral IV was started in the patient's left arm on 10/21/11. She went on say she better change the IV site today.

An interview was conducted with S3Quality Assurance Director on 10/26/11 at 1:30 p.m. She reported with review of the Electronic Medical Records, the IV in the patient's left arm was started on 10/20/11. The hospital's policy was for a peripheral IV to be in 72 hours and if for some reason the nurse felt the patient's IV site didn't need to be changed, the nurse should notify the doctor. She went on to report there was no documentation a nurse notified the doctor that the IV site was left in for 6 days instead of the hospital policy of 72 hours only.

Based on record review and interview the hospital failed to have medical records promptly completed after discharge for 2 out of 10 medical records reviewed ( R1 and #7).

Finding:
Review of the medical record for Patient #7 revealed he was admitted on 08/18/11 and transferred to hospital "a" on 08/18/11. Review of the medical record revealed no discharge summary on the medical record.

An interview was conducted with S14Health Information Director on 10/26/11 at 2:05 p.m. She confirmed there was not a discharge summary on the medicial record for Patient #7. She went on to state the physician had 30 days to complete the medical record including the discharge summary, if the the medical record was not completed within 30 days the chart was considered delinquent.

Review of the Medical Staff Bylaws revealed in part, "... Records of discharged patients shall be completed within thirty days (30) of the discharge date..."

Review of the medical record for Patient #7 revealed the following orders were not authenticated by the ordering physician; an order dated 08/18/11 and timed 0710 (7:10 a.m.),an order dated 08/18/11 and timed 1320 (1:20 p.m), an order dated 08/18/11 and timed 1430 (2:30 p.m.), an order dated 08/18/11 and time 1120 (11:20 a.m.), an ordered dated 08/18/11 and timed 1225 (12:25 p.m.) and the order for the discharge medications for the patient ordered 08/18/11 at 1420 (2:20 p.m.).

Review of the medical record for Patient R1 revealed the following verbal orders were not authenticated; an ordered dated 09/08/11 and timed 1206 (12:06 p.m.) and an order for the patient's discharge medications on 09/08/11.

An interview was conducted with S14Health Information Manag on 10/26/11 at 2:05 p.m. She stated verbal orders are to be signed within 72 hours by the ordering physician.

Review of the Medical Staff Bylaws revealed in part,"...All orders dictated over the telephone shall be signed by the appropriately authorized person with the name of the Practitioner and his own name. The responsible Practitioner shall authenticate such orders within 72 hours..."

Review of the 2011 Delinquent Medical Records statistics provided by S14Health Information Manager revealed in July 2011 ( the last month that statistics were provided) the delinquent medical record rated was 43%. There were 300 delinquent medical records out of a total number of 696 discharged medical records.

Based on record review and interviews the hospital failed to have verbal orders authenticated within 72 hours for 2 out 8 medical records reviewed for medical orders (R1, #7).

Findings:

An interview was conducted with S14Health Information Manager on 10/26/11 at 2:05 p.m. She stated verbal orders are to be signed within 72 hours by the ordering physician.

Review of the medical record for Patient #7 revealed the following orders were not authenticated by the ordering physician; an order dated 08/18/11 and time 0710 (7:10 a.m.),an order dated 08/18/11 and timed 1320 (1:20 p.m), an order dated 08/18/11 and timed 1430 (2:30 p.m.), an order dated 08/18/11 and time 1120 (11:20 a.m.), an ordered dated 08/18/11 and timed 1225 (12:25 p.m.) and the order for the discharge medications for the patient ordered 08/18/11 at 1420 (2:20 p.m.)

Review of the medical record for Patient R1 revealed the following verbal orders were not authenticated; an ordered dated 09/08/11 and time 1206 (12:06 p.m.) and an order for the patient's discharge medications on 09/08/11.

Review of the Medical Staff Bylaws revealed in part,"...All orders dictated over the telephone shall be signed by the appropriately authorized person with the name of the Practitioner and his own name. The responsible Practitioner shall authenticate such orders within 72 hours..."

Based on record review and interviews the hospital failed to have a hospital policy in place to address the criteria for which specific patients could be transferred to another hospital by private vehicle versus an ambulance for 2 out of 4 patients reviewed for transfer to another hospital (R1, #4) Findings:

Patient R1
Review of the medical record for Patient R1 revealed he was a 62 year old male admitted to the hospital on 09/05/11 for shortness of breath. A CT scan of his chest was performed and a mass was found in the right upper lobe surrounded by post obstructive pneumonia. On 09/08/11 he was transferred to hospital "b" for a mediastinoscopy with biopsy of a lymph node.

Review of his physician orders dated 09/08/11 revealed an order to transfer to hospital "b" per private vehicle.


Patient #4

Review of Patient #4's medical record revealed her discharge summary stated in part, " The patient is a 20 year old noncompliant diabetic who presented to the emergency room with persistent nausea and vomiting. She had a history of having a gastric sleeve done by S16MD. 3-4 months prior to admission. She states that she has felt nauseated and started throwing up. She was seen in the emergency room, was diagnosed with dehydration and urinary tract infection a couple days prior to admission and was given Bactrim, however re-presented to the emergency room after persistent nausea and vomiting and dehydration. Evaluation in the emergency room found that she had a mildly elevated lipase with dehydration and hyperglycemia. She was subsequently admitted to the hospital for hydration and further workups. She underwent multiple laboratory evaluations, all of which were essentially normal except for some mild anemia and her electrolytes had some minimal abnormalities. Initially her amylase and lipase were 145 and 988. Those went up at the time of transfer to 171 to 1301. Imaging studies including an upper GI was normal. A CT (computed tomography) showed a small amount of free fluid in the cul-de-sac but otherwise normal, acute abdominal series was normal. Ultrasound showed Cholecystectomy, otherwise normal. In spite of IV hydration and antiemetics she continued to be with persistent vomiting. I spoke with S16MD about the possibility that this could be complication of her gastric sleeve. He asked us to do the swallow study, which turned out to be normal. However because of the persistence of her syptomatology she was subsequently transferred to Hospital "a" for further evaluation by S16MD and the GI doctors. At the time of discharge her condition was good. Her vitals were stable. Her physical exam was essentially normal except for the fact that she could not hold down p.o. (by mouth) intake. She will be followed by the hospitalist and the GI doctor and S16MD at Hospital "a" and they will keep us posted on her progress. "

An interview was conducted with S13MD on 10/25/11 at 8 a.m. She reported she was the Chief of Staff at Lane Regional Memorial Hospital and her specialty was Family Practice. She went on to report whenever there was a complaint given to the hospital related to a physician, the Medical Executive Committee reviews the complaint. She stated she was one of the physicians that reviewed the complaint against the care doctor S6MD provided to Patient #4. With review of the case the Medical Executive Committee found no problems with the care provided and with the private vehicle transport to Hospital "a" . She went on to state the patient was stable and she found no problem with transporting the patient with the heparin lock. She also reported that other patients hospitalized at Lane Regional Medical Center had been transported by private car to another hospital if they were stable.

Review of the Hospital policy for Transfer in part revealed, " ... 7. The nurse will contact the appropriate transportation if the patient is not allowed to go via private automobile." Review of the hospital's policy for transferring a patient to another facility and the hospital policies on discharge planning revealed no criteria for which patients are able to be transported by private automobile versus ambulance.

An interview was conducted with S3Director of Quality Assurance on 10/27/11 at 9:00 a.m. She stated the hospital had no criteria for which patients could be transferred to another hospital by ambulance versus private automobile.