HospitalInspections.org

Based on review of records, interviews with staff, review of hospital documents, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent through the hospital's grievance process. Seven of seven complaints/grievances documented on the complaint/grievance log had not been correctly identified, reviewed and resolved through the grievance process.

Findings:

1. On 1/11/2012 surveyors reviewed the complaint and grievance log. Seven grievances (#1,4,5,6,7,9,10) were reviewed. Six of seven grievances either were not correctly identified as a grievance, did not have a written response with all required elements, or did not have all required elements.

Patient #1 included multiple care complaints with nursing and dietary. The grievance was initially submitted verbally by the patient's family during the stay. There was no documentation the concerns were documented in the complaint grievance log. The hospital failed to identify the complaint as a grievance and failed to provide timely follow up to the complainant.

Patient #4 a grievance was voiced by the patient's family member. Several concerns were identified by the complainant. There was no documentation the complainant received a written response with all of the required information. There was no documentation indicating what steps were taken to investigate all of the concerns.

Patient #5 A grievance was submitted by the significant other after the patient was discharged. Review of the medical record indicates the patient complained about care to the physician. There was no documentation the physician notified staff or triggered the complaint/grievance process.

Grievance#6 The grievance was submitted by family members. The complainant alleged multiple issues with care and quality of care. There was no documentation the steps taken to investigate the complaint. The response letter was sent to the patient not the complainant.

Patient #7-documents provided to surveyors on 1/11/12 indicate a grievance was voiced regarding food and nutritional services. There was no documentation the complainant received a written response with all of the required information.

Patient #10 had complained via the telephone to staff. The complaint required an investigation before it could be resolved. The grievance/complaint log did not identify the complaint as a grievance. There was no documentation the grievance was reviewed through the grievance process.

Patient #9 complained regarding extended wait times. The complaint required an investigation before it could be resolved. The grievance/complaint log did not identify the complaint as a grievance. There was no documentation the grievance was reviewed through the grievance process.

Based on a review of policies and procedures, complaint/grievance reports, and staff interviews, the hospital failed to ensure a grievance process meeting all the required elements was implemented throughout the organization. Seven(1,4,5,6,7, 9,10)of seven complaints/grievances were not identified correctly, did not contain the steps taken on behalf of the patient/complainant to investigate the grievance, the results of the grievance process, or or did not address the complainant.

Findings:

1. According to documents received at the Department, Patient #1's (the patient mentioned in the complaint) family member complained to the charge nurse about care on 6/11/11. The complainant spoke with (Name Withheld) who identified himself as the head nurse on 6/11, 6/13, and 6/15 regarding care concerns. The complainant stated she spoke with (name withheld) in administration and the head nurse was sent to discuss concerns again on 6/15/11. Surveyors were provided documents on 1/11/12 identified as the grievance/complaint log from June 2011 to January 2012. None of the occurrences were documented in the grievance/complaint log. There was no evidence the grievance had been reviewed through the grievance process.

2. Patient #6 - documents provided to surveyors on 1/11/12 indicate a grievance was voiced to staff by the patient's family member. There was no documentation the complainant received a written response, with all of the required information.

3. Patient #7-documents provided to surveyors on 1/11/12 indicate a grievance was voiced regarding food and nutritional services. There was no documentation the complainant received a written response with all of the required information.

4. Patient #4 documents provided to surveyors on 1/11/12 indicate a grievance was voiced by the patient's family member. Several concerns were identified by the complainant. There was no documentation the complainant received a written response with all of the required information. There was no documentation indicating what steps were taken to investigate all of the concerns.

5. Patient #5 A grievance was submitted by the significant other after the patient was discharged. Review of the medical record indicates the patient complained about care to the physician. There was no documentation the physician notified staff or triggered the complaint/grievance process.

6. On 1/12/12 Staff C told surveyors the hospital did not send responses to complainants other than patients. Staff D indicated the hospital did not acknowledge the complainants because of HIPAA (Health Information Portability and Accountability Act) and disclosure of PHI (Protected Health Information) reasons.

7. Patient #10 had complained via the telephone to staff. The complaint required an investigation before it could be resolved. The grievance/complaint log did not identify the complaint as a grievance. There was no documentation the grievance was reviewed through the grievance process.

8. Patient #9 complained regarding extended wait times. The complaint required an investigation before it could be resolved. The grievance/complaint log did not identify the complaint as a grievance. There was no documentation the grievance was reviewed through the grievance process.

Based on review of hospital documents, quality improvement meeting minutes, medical records and grievances and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) program failed to identify and analyze process of care issues identified by the surveyors and voiced by patients/patient representatives.

Findings:

1. The QAPI program does not ensure all grievances are recorded/identified and placed through the grievance process. Refer to Tags A-0119 and A-0123 for findings.

2. Issues identified by the surveyors concerning communications, between nursing and surgical services and nursing and dietary services, that potentially affect patient care, have not been recognized and analyzed through the QAPI process to improve patient care and health outcomes. Refer to Tag A-395 for details.

Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. This occurred in four of six (Record #1, 2, 3 and 8 of Records #1, 2, 3, 4, 5 and 8) reviewed.

Findings:

1. In three of five (Records #1, 2, and 8) patient records reviewed, the nurse did not perform complete assessments of new surgical patients upon arrival to the unit from recovery room.
a. Patient #1 - According to documentation, after surgery on 06/07/2011, the patient left the recovery room around 1315. The nurse on the unit did not perform an assessment of the patient until 1400. This finding was reviewed and verified with Staff A at the time of review on the afternoon of 01/11/2012.

b. Patient #2 - According to documentation, the patient arrived on the nursing unit from recovery room on 12/29/2011 at 2030, but the nurse did not perform a nursing assessment until 2300.

c. Patient #8 - According to documentation, the patient arrived on the nursing unit from recovery room on 06/07/2011 at 1742. The nurse did not perform an assessment of the patient until 1945. The nursing assessment at 1945, was not performed by the nurse on duty when the patient arrived on the unit, but by the following shift nurse - two hours after the patient's arrival. This finding was reviewed and verified with Staff A at the time of review on the afternoon of 01/11/2012.


2. In three of three (Records #1, 3, and 8) patient records reviewed whose surgeries were postponed, the nurse did not supervise nursing personnel and patient care to ensure patients were not left without nutrition/diets for extended periods of time.

a. Patient #1 - The patient arrived at the emergency room (ER) on 06/05/2011 at 1000. According to documentation, the first recorded food eaten was breakfast on 06/08/2011- after surgery on 06/07/2011. The patient did not arrive on the unit from ER until 1850 on 06/05/2011. The medical record did not contain evidence the patient was provided any nutrition while in the ER. The medical record documented, while in the ER the patient was seen by the orthopedic services and it was decided to schedule the patient for surgery the next day, 06/06/2011. According to the dictated operative report, the patient's surgery was postponed until 06/07/2012 because of abundance of emergency surgeries.

b. Patient #3 - The patient arrived in the ER on 06/18/2011. The first recorded nutrition/food intake was after surgery on 06/20/2011. The patient was originally scheduled for surgery on 06/19/2011, but was postponed because of the patient's condition. Although the physician ordered a regular diet for the patient when surgery was postponed on 06/19/2011, the medical record did not contain evidence the nurse supervised to ensure the patient was provided appropriate nutrition.

c. Patient #8 - The patient arrived in the ER on 06/05/2011 at 1150. The first recorded nutrition/food intake recorded was 06/09/2011 - the day after the patient's surgery on 06/07/2011. The patient did not arrive on the nursing unit from the ER until 1825. ER documentation did not demonstrate the patient was offered/provided nutrition while in the ER. The patient was seen by orthopedic services in the ER and it was decided to schedule the patient for surgery on 06/06/2011. Because of the reason cited in Finding #2a, the surgery was postponed until 06/07/2011.

3. For Patients #1 and 8, review of hospital documents and medical record and interviews with hospital staff, did not demonstrate the nursing supervisor ensured communications between operating room staff and the nursing unit were performed to provide information so nursing care could be updated and patient's nutritional status could be reevaluated. Staff E told the surveyor on 01/10/2011 that they did not call the unit to relay delays in surgery times.

Based on a review of policies and procedures, medical records, patient grievances, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. In three of three (Records #1, 3, and 8) patient records reviewed whose surgeries were postponed, there was no documentation indicating nutritional services assessed or intervened on behalf of patients to ensure diets met the needs of the patients.

a. Patient #1 - The patient arrived at the emergency room (ER) on 06/05/2011 at 1000. According to documentation, the first recorded food eaten was breakfast on 06/08/2011- after surgery on 06/07/2011. The patient did not arrive on the unit from ER until 1850 on 06/05/2011. The medical record did not contain evidence the patient was provided any nutrition while in the ER. The medical record documented, while in the ER the patient was seen by the orthopedic services and it was decided to schedule the patient for surgery the next day, 06/06/2011. According to the dictated operative report, the patient's surgery was postponed until 06/07/2012 because of abundance of emergency surgeries.

b. Patient #3 - The patient arrived in the ER on 06/18/2011. The first recorded nutrition/food intake was after surgery on 06/20/2011. The patient was originally scheduled for surgery on 06/19/2011, but was postponed because of the patient's condition. Although the physician ordered a regular diet for the patient when surgery was postponed on 06/19/2011, the medical record did not contain evidence the nurse supervised to ensure the patient was provided appropriate nutrition.

c. Patient #8 - The patient arrived in the ER on 06/05/2011 at 1150. The first recorded nutrition/food intake recorded was 06/09/2011 - the day after the patient's surgery on 06/07/2011. The patient did not arrive on the nursing unit from the ER until 1825. ER documentation did not demonstrate the patient was offered/provided nutrition while in the ER. The patient was seen by orthopedic services in the ER and it was decided to schedule the patient for surgery on 06/06/2011. Because of the reason cited in Finding #2a, the surgery was postponed until 06/07/2011.

3. For Patients #1 and 8, review of hospital documents, medical records, and interviews with hospital staff, did not demonstrate the food and nutritional services personnel communicated with other departments to ensure patients received appropriate nutrition. According to Staff G, the food and nutritional services would not intervene unless notified by nursing, or the patient remained NPO (without anything by mouth) for five days, or there were other health conditions which would trigger a nutritional assessment by the dietitian. There was no documentation food and nutritional services was aware postponed surgical patients did not receive diets.