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Based upon record review and interview, the hospital failed to ensure the grievance process investigated complaints/grievances and provided a response to the patient or the patient's representative. This was evidenced by patient #1's representative filing a verbal complaint related to care and the failure to conduct a thorough investigation into complaints the patient was dehydrated and had pills in his mouth when he was transferred on 9/30/15 unresponsive to an acute care hospital. Findings:

Review of the policy #508.3 titled "Patient Family Complaint/Grievance" adopted May 2006 revealed "Procedure: #2. Complaints will be documented on a Grievance Report and brought to the immediate attention of the CEO, who will present the complaint to the Grievance Committee. The Grievance Committee, as determined by the Board of Directors, consists of the CEO, Chief Nurse Officer, and the Clinical Therapist of Allegiance Health Center of Ruston. The Grievance Committee will investigate the complaint within 24 hours and will: a. document the results of the investigation on the Complaint Form, b. The complaint/grievance will be reviewed for necessary notification of external agencies, State Agency for Abuse Reporting and Patient Rights/Advocacy Offices."

Interview with S1DON on 10/27/15 at 1:30 p.m. revealed the daughter of patient #1 had called her wanting to let her know the "kind of care" her father had received while a patient in the hospital. S1DON provided a handwritten document dated 10/2/15 related to the complaint and her investigation of the allegations that when patient #1 was transferred unresponsive to an acute care hospital, he was dehydrated and still had pills in his mouth. According to the documented investigation conducted by S1DON, she reviewed the patient's medical record and found on 9/29/15 the patient had drank a milk shake and juice, was refusing to eat or drink and had received no medications for the 12 hours prior to his transfer. S1DON further added all the patient's medications were crushed and mixed with applesauce.

S1DON provided another form titled Mortality Review which identified patient #1's name, date of admission, admitting and final diagnoses. The form also identified "Does the chart reflect documentation that the patient's medical condition at the time of admission DID NOT preclude their ACTIVE PARTICIPATION in treatment and "yes" was check marked. The form further identified the patient was transferred to an acute care hospital.

Review of patient #1's medical record revealed on the morning of 9/30/15, the nurse did crush the patient's medications, mixed them with applesauce; however, the patient spit the medications out. Review of the investigation conducted by S1DON identified the patient had not received any medications for 12 hours prior to transfer. Review of the medical record from the acute care hospital revealed the patient required oral suctioning to remove the pills from his mouth.

Based on record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by pulling a patient's bed into the door way for 1 (#1) of 5 sampled patients who required increased observations.
Findings:

Review of the medical record for patient #1 revealed an admission date of 09/10/15 with a diagnosis of dementia with depression and behavioral disturbances. The admission nursing assessment dated 09/10/15 revealed the patient was confused and anxious. Review of the fall risk assessment performed on admit revealed the patient was at moderate risk for falls and would be placed on "Level II-Constant Monitoring-Within View". Further review of the fall risk assessment form revealed the patient was also assessed on 09/17/15 and 09/24/15 to be at moderate risk for falls, indicating an observation level of "Level II-Constant Monitoring-Within View".

Review of the Patient Observation Records revealed the patient was receiving routine observations, indicating every 15 minutes.

Review of the patient's nurses notes dated 09/24/15 at 6:00 a.m. revealed the nurse went into the patient's room to provide morning care and found patient on the floor.

Interview with S3LPN on 10/27/15 at 11 a.m. revealed that staff would pull the patient's bed into his door way to observe him more closely. S3LPN stated that the patient would frequently attempt to get out of bed and would throw his legs over the sides of the bed.

Interview on 10/27/15 at 2:30 p.m. with S1DON confirmed that staff would pull patient #1's bed to his doorway so they could watch him closer. S1DON stated that the patient required constant observations at that time due to his behaviors and fall risk. S1DON further confirmed that a staff member should have been sitting with the patient in his room instead of pulling his bed to the doorway.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to assess skin turgor for dehydration for 1 of 1 sampled patient (#1) who was refusing to eat and/or drink in a total sample of 5; and
2) failing to obtain a physician order to treat pressure sores until 4 days after being identified for 1 of 1 sampled patient (#1) with pressure sores in a total sample of 5.
Findings:


1) Failing to assess skin turgor for dehydration

Review of the medical record for patient #1 revealed an admit date of 09/10/15 with a diagnosis of dementia with depression and behavioral disturbances. The nursing admission assessment dated 09/10/15 revealed the patient was dependent on staff for activities of daily living.

Review of the nurses notes dated 09/25/15 revealed that the patient refused all attempts to get him to eat or drink. The nurses notes dated 09/26/15 revealed the patient refused anything by mouth. Review of the nurses notes dated 09/29/15 revealed that the patient was refusing to eat. The nurses notes dated 09/30/15 revealed that the patient was not eating or drinking.

Review of the physician orders dated 09/14/15 revealed an order to force fluids with 12 ounces ever 3-4 hours. Review of the physician orders dated 09/23/15 revealed orders to push oral fluids. Physician orders dated 09/25/15 and 09/26/15 revealed orders to continue to force fluids.

Review of the patient's intake record from 09/27/15 to 09/30/15 revealed that his oral intake ranged from 404 cc to 887 cc per 24 hours.

Review of the Nursing Shift Physical Assessment forms dated 09/27/15 through 09/30/15, when the patient was transferred to the hospital for dehydration, revealed no documented evidence that the patient's skin turgor was assessed to determine dehydration. Further review of the nurses notes from 09/27/15 through 09/30/15 revealed no documented evidence of assessments of the patient's skin turgor.

On 10/27/15 at 9:30 a.m., S1DON reviewed patient #1's record and confirmed that there was no documented evidence that the patient's skin turgor was assessed for dehydration from 09/27/15 until transfer to the hospital on 09/30/15.


2) failing to obtain a physician order to treat pressure sores until 4 days after being identified

Review of the medical record for patient #1 revealed a nursing admission assessment dated 09/10/15 stating that the patient had no pressure sores. Review of the patient's Pressure Ulcer/Wound Flowsheet revealed three Stage II pressure sores were identified on 09/25/15. The flowsheet did not state the locations of the pressure sores.

Review of the nurses notes dated 09/25/15 revealed no documentation related to pressure sores. Review of the Nursing Shift Physical Assessment form dated 09/25/15 (7A-7P shift) revealed that the patient had a Stage II pressure sore to the coccyx and a black area to the left great toe. There was no further assessment of the pressure sores and no evidence that the patient's physician was notified in order to obtain treatment orders.

Review of the Nursing Shift Physical Assessment form dated 09/26/15 revealed the patient had a Stage II to the coccyx and the left great toe. Review of the Nursing Shift Physical Assessment forms dated 09/27/15 through 09/29/15 revealed the patient had a Stage II to the buttocks. There was no further documentation related to the pressure sore to the left great toe.

Further review of the medical record revealed a physician order was obtained on 09/29/15 (4 days after being identified) for "wound care to buttocks daily". There was no specific treatment ordered for the buttocks and no order was obtained to treat the pressure sore to the left great toe. Review of the patient's medication/treatment administration record dated 09/29/15 revealed the nurse documented that wound care to the buttocks was performed. There was no documentation of what type of treatment was performed.

On 10/27/15 at 9:30 a.m., S1DON reviewed patient #1's record. S1DON confirmed that three pressure sores were identified on 09/25/15 but she was unable to determine where all three were located. S1DON further confirmed that a physicians order was not obtained until four days after identifying the pressure sore to the buttocks. She stated that the physician order was not specific and that the nursing staff should have gotten clarification by the physician.

Based upon record review and interviews, the hospital failed to identify physical problems in 2 of 5 patient treatment plans. This was evidenced by 1) failure to identify patient #1's refusal to eat/drink and the development of pressure sores and 2) failure to identify patient #4 had a 5 pound weight loss within one week after admission. Findings:

1) Review of the medical record for patient #1 revealed an admit date of 09/10/15 with a diagnosis of dementia with depression and behavioral disturbances.

Review of the nurses notes dated 09/25/15 revealed that the patient refused all attempts to get him to eat or drink. The nurses notes dated 09/26/15 revealed the patient refused anything by mouth. Review of the nurses notes dated 09/29/15 revealed that the patient was refusing to eat. The nurses notes dated 09/30/15 revealed that the patient was not eating or drinking.

Review of the physician orders dated 09/14/15 revealed an order to force fluids with 12 ounces ever 3-4 hours. Review of the physician orders dated 09/23/15 revealed orders to push oral fluids. Physician orders dated 09/25/15 and 09/26/15 revealed orders to continue to force fluids.

Review of the patient's intake record from 09/27/15 thru 09/30/15 (when he was transferred to the acute care hospital with dehydration) revealed that his oral intake ranged from 404 cc to 887 cc per 24 hours.

Further review of the patient's record revealed the Pressure Ulcer/Wound Flowsheet had documentation that three Stage II pressure sores were identified on 09/25/15.

Review of the patient's Master Treatment Plan revealed that the patient's refusal to eat/drink and his development of pressure sores was not identified.

2) Review of patient #4's medical record revealed the patient was admitted to the hospital on 10/10/15 with the diagnosis of Atypical Depression, Confusion, and Delusions. Upon admission the patient's weight was 139 pounds. The next weight documented was 134 pounds on 10/20/15. Review of the Dietary Manager's notes dated 10/20/15 identified the patient's albumin level was low and suggested the patient consume a can of Ensure twice a day. Review of the Master Treatment Plan revealed the patient's weight loss and low albumin level was not identified.