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Based on interviews and document review, the facility failed to ensure patients or their representatives who reported grievances were provided written responses of the findings from the facility's investigation of the issues reported by the complainant in 2 of 3 grievance documentation records reviewed (Patients #2 and #10).

This failure resulted in a deviation from the facility's approved grievance process and the potential for patients or their representatives to be unaware of the outcome of their grievance.

FINDINGS

POLICY

According to Patient Grievance Mechanism Plan, in the resolution of the grievance, the facility will provide the patient with a written response of its decision that will contain: the facility's contact person; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the date of completion. Contact information for other individuals or entities the patient may contact, if they are not satisfied with the Patient Advocate's response, will be provided in the written response.

1. The facility failed to send written responses regarding the facility's contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in accordance with the facility's policy.

a) Review of the Patient Experience Coordinator's (PEC #1) grievance documentation revealed Patient #2 and his/her nephew called on 09/27/16 and spoke with PEC #1 regarding the care of Patient #2. Care concerns included the patient receiving medication s/he was allergic to and the patient's blood pressure on discharge was elevated and not addressed appropriately by staff.

A letter dated 09/28/16, one day after Patient #2 called PEC #1 with concerns, was addressed to Patient #2. The letter thanked him/her for sharing concerns and stated the concerns were being investigated by the Quality Outcomes Department. No further documentation was found notifying Patient #2 or his/her family of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation. This was in contrast with the facility's Grievance Mechanism Plan.

b) Review of PEC #1's grievance documentation revealed Patient #10 called on 09/13/16 and spoke with PEC #1 regarding concerns from a recent hospital visit regarding Patient #10 receiving narcotic pain medications after s/he requested none be given due to severe allergies and sensitivities to these medications in the past.

A letter dated 09/13/16, the same day Patient #10 called PEC #1 with concerns, was addressed to Patient #10. The letter thanked the patient for sharing concerns and stated the concerns were being investigated by the Quality Outcomes Department. No further documentation was found notifying Patient #10 of the steps take on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

c) On 01/05/17 at 1:36 p.m., an interview was conducted with PEC #1 and the Vice President of Quality (VP #2). PEC #1 stated his/her role included documenting and taking care of grievances received at the facility. PEC #1 stated s/he did not send written documentation to complaints after the investigation was completed notifying them of the results of the investigation.

During the same interview, VP #2, revealed s/he was previously in charge of the grievance process for the facility. VP #2 stated s/he was not aware that sending written notification of the results of grievance investigations to complainants was required.

Based on interviews and document review, the facility failed to ensure an order was obtained from a physician or Licensed Independent Practitioner (LIP) prior to the initiation of physical restraints in 1 of 4 medical records reviewed of patients with documented use of physical restraints (Patient # 2).

This failure created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to Patient Restraint/Seclusion, an order for restraints or seclusion must be obtained from a LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. When a LIP/physician is not available to issue a restraint or seclusion order, a RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.

1. The facility did not ensure restraint orders were obtained prior to or immediately after placing patients in physical restraints.

a) Review of the Clinical Documentation record, dated 07/02/16, revealed Patient #2 was in non-violent physical restraints on 07/02/16 at 10:00 p.m.; however, there was no order for restraints until 07/03/16 at 2:45 p.m. (16 hours and 45 minutes after the restraints had been initiated). This was in contrast to the policy which stated to notify a practitioner immediately, within a few minutes, to obtain an order.

b) On 01/05/17 10:10 a.m., an interview was conducted with Registered Nurse (RN #3), who recalled caring for Patient #2 on the night shift of 07/02/16. RN #3 stated s/he would typically obtain a verbal order from a physician to initiate restraints and then s/he would enter the order in the electronic order system. RN #3 stated s/he thought s/he had entered the physician's order for initiating restraints for Patient #2; however, after reviewing the medical record with RN #3, no documentation regarding restraints was found. RN#3 stated the facility's expectation was for staff to obtain a doctor's order within the hour of initiation of physical restraints.

c) On 01/04/17 at 2:50 p.m., an interview was conducted with the Chief Nursing Officer (CNO #7). After reviewing the Medical Record of Patient #2, CNO #7 confirmed restraints were initiated on 07/02/16 at 10:00 p.m. and there was no order to initiate restraints until 07/03/16 at 2:45 p.m. CNO #7 stated this was outside of the expectation and policy of the facility for restraints.

Based on interviews and document reviews, the facility failed to ensure patients with allergies did not receive medications they were documented to be allergic to in 1 of 10 medical records reviewed (Patient #2).

This failure resulted in a patient receiving a medication s/he was allergic to.

FINDINGS

POLICY

According to Patient Assessment and Reassessment, all admitted patients will have the following data collected/addressed in their initial screening (based on the patient's condition): Allergies.

According to Medication Errors, medication errors, including errors that do not reach the patient must be reported promptly and accurately via the Clinical Patient Care System Occurrence Reporting process in an effort to identify opportunities to improve the medication use process.

Types of errors include, but are not limited to: contraindication/allergy: Administration of a medication that has contraindications with the patient's current regimen or disease state or the patient has a stated allergy to the medication.

1. Facility staff administered two doses of morphine to a patient with a documented allergy to the medication.

a) Review of Patient #2's Emergency Patient Record (EPR) revealed the patient presented to the Emergency Department (ED) on 07/02/16 at 6:43 p.m. with a chief complaint of vertigo and dizziness. The only allergy listed on the Allergies section of the EPR was sulfonamide antibiotics (Sulfa) with an unknown reaction, which was verified on 07/02/16.

Review of Patient #2's History and Physical (H&P) on 07/02/16 at 9:57 p.m. revealed the patient presented to the ED on 07/02/16 with a chief complaint of syncope. Patient #2's care plan included a referral to a cardiology physician with plans to urgently take the patient to the catheterization laboratory for placement of a temporary pacemaker. Sulfonamide antibiotic (Sulfa) was the only allergy documented under the Coded Allergies section of the H&P.

Patient #2's medical record revealed faxed documents were received from a separate health care facility on 07/02/16 at 7:49 p.m. The documents included information of Patient #2's medical history, including current medications and allergies. Patient #2 was listed as having 4 allergies under the Allergies section of the document. Allergies listed included Morphine Sulfate, which was noted on 02/05/02 with reactions documented as "skin rash and/or hives, other".

Patient #2's Emergency Patient Record showed documentation from RN #2 on 07/02/16 at 8:24 p.m., which stated the patient's nephew asked if Patient #2's medication list from a separate health care facility was seen by anyone. The physician stated "yes, I physically saw it and reviewed all of his/her medications."

According to Patient #2's physician orders, on 07/02/16 at 9:45 p.m., Morphine, 2 milligrams (mg) via intravenous (IV) route every four hours as needed for pain was ordered. The order was discontinued on 07/03/16 at 9:35 a.m.

Review of Patient #2's Medical Administration Record (MAR) revealed the patient received 2 doses of Morphine by Registered Nurse (RN #1); the first dose given on 07/03/16 at 12:40 a.m. and the second dose given on 07/03/16 at 6:22 a.m.

Review of Patient #2's Allergy History revealed Morphine was added to the patient's allergy list on 07/05/16 at 12:07 p.m. by Pharmacist #3, which was 3 days after the documented receipt of the fax stating the patient was allergic to Morphine.

b) On 01/05/17 at 10:59 a.m., and interview was conducted with RN #4 who revealed s/he worked as a nurse in the ED. RN #4 stated typically allergies were assessed and documented by the ED nurse during the initial triage process. If documents from an outside facility containing patient medical information were received by the ED nurse, the expectation was for the nurse to make a photo copy of the document, label the document with the patient's identification information and place the document in the medical record. RN #4 stated allergy information could be updated at any time during the patient's visit.

RN #4 recalled caring for Patient #2 in the ED on 07/02/16. RN #4 stated s/he remembered Patient #2's family asking if staff had received the patient's medication list. RN #4 further recalled Patient #2's physician discussing the patient's medication list with the family. However, RN #4 stated s/he did not recall if allergies were discussed at this time. RN #2 further stated s/he never saw the medication list from the outside facility.

c) On 01/05/17 at 10:10 a.m., in interview was conducted with RN #3 who revealed s/he worked in the ICU. RN #3 stated when receiving a new patient s/he would typically verify the patient's allergies and reactions with the patient. RN #3 then recalled caring for Patient #2 on the night shift of 07/02/16. RN #3 stated s/he did not remember seeing a faxed document with Patient #2's allergies listed before s/he administered Morphine to the patient. RN #3 stated s/he did recall Patient #2 telling him/her about having nausea after receiving morphine a long time ago. RN #3 further stated s/he thought s/he had documented the morphine in the sensitivities section of the medical record; however, after reviewing the medical record with RN #3, no documentation regarding morphine sensitivity was found.

d) On 01/15/17 at 9:49 a.m., an interview with Pharmacist #5 was conducted. Pharmacist #5 stated the process for assessing and documenting patient allergies began when the patient arrived at the facility. The patient's nurse or physician was expected to ask the patient about allergies and enter them into the medical record. The pharmacist would then clarify any missing allergy information with either the patient or the patient's nurse.

After reviewing the allergy section of Patient #2's medical record, Pharmacist #5 verified that s/he had entered the patient's allergy information on 07/05/16 from the document received on 07/02/16 from a separate health care facility. Pharmacist #5 stated s/he could not remember how s/he had received the faxed document or why the allergy information had not been entered into Patient #2's medical upon receipt of the document.

Pharmacist #5 stated if s/he had known Patient #2 had received Morphine and Benadryl, s/he would have entered the incident as an occurrence. Pharmacist #5 further stated anyone could have entered the incident into the occurrence system in order for the incident to be looked at more closely by the facility.