HospitalInspections.org

Based on document review and interview, it was revealed that the facility failed to follow their policy on complaints and grievances for one (1) patient, patient #1. This failure has the potential to negatively impact all patients expressing a complaint at the facility.

Findings include:

Review of the complaint log for the last three (3) months revealed that no complaint was logged on patient #1's behalf.

Review of the policy titled, "Patient Complaints and Grievances," last revised 12/19/22, states in part Section V, Article A, "The receiver of the complaint shall make a reasonable attempt to resolve the complaint promptly. Upon resolution, the receiver of the complaint shall complete documentation of the event using the online event reporting system. The Patient Advocate shall review the online event report including the resolution action(s) and close the complaint when resolved."

A review was conducted of the training file for the Nurse Manager (NM). The NM received "Rapid Regulatory Compliance: Clinical 1 and Clinical 2" on 12/07/22, which includes the patient complaint and grievance process. The NM received "Midas: Managing Risk Events" and "Midas: Risk Event Reporting" which is the system used for entering complaint data information, on 10/26/22.

An interview was conducted with the Physician Assistant-Certified (PA-C) on 02/16/23 at 9:00 a.m. Regarding patient #1, the PA-C states, "Not until we sent the patient to ICU was when the family had complaints. There were only a couple complaints, both related to nursing. I remember one (1) was about suction and one (1) was about recording vitals- both happened on the fifth (5th) floor. I took the complaints to the nurse manager."

During an observation on 02/16/23, an interview was conducted with NM at 10:30 a.m. regarding patient #1. The NM explained that NM had received a complaint from [patient #1's family member] regarding nursing care of patient #1. NM explained that additional staff education was completed during morning briefings to address the complaint received from [patient #1 ' s family member] and a mass email. NM states, "I addressed the complaint with the nursing staff but did not document it in [the online event reporting system]. [Patient #1] was moved off the floor later the same day, so I did not follow up with [patient #1's family member]".

An interview was conducted with the Director of Respiratory Services and a Respiratory Therapist on 02/16/23 at 9:53 a.m. Regarding a complaint about using the same suction, the Director of Respiratory Services states, "I never received a complaint about my staff using the same suction. After finding out about this incident, I did review the documentation. Our staff would not document if they just did an oral suction, so I'm not sure which respiratory therapist would have been involved. If I would have known about this complaint at the time, I could have better investigated it and then re-educated all my staff to ensure it didn't happen again."

An interview was conducted with the Patient Advocate/Guest Services Supervisor on 02/16/23 at 10:48 a.m. Regarding the complaint with patient #1, The Patient Advocate/Guest Services Supervisor states, "At the time the complaint was received by the PA-C, it was taken up the proper chain of command, which would have been to tell the nurse manager. If the patient was no longer on the unit, the nurse manager could have passed it onto the nurse manager of the new unit or could have contacted the patient advocate. The complaint still should have been documented in [online event reporting system]. Anyone can put documentation in[online event reporting system]. We could have followed up with this complaint if we would have known about it."

Based on medical record review, document review, and interview, it was revealed the facility failed to follow nursing policies and procedures by not ensuring a blood consent was present prior to administration of blood products in one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact any patient receiving blood products at the facility.

Findings include:

A record review was conducted for patient #1. The patient presented to the facility Emergency Department (ED) on 12/31/22 at 12:00 p.m. via private vehicle. The patient's platelet count was twenty (20). The patient was ordered one (1) unit of platelets. The platelets were administered on 01/01/23 at 4:07 p.m. No consent for blood products was in the electronic medical record.

A review was conducted of the policy titled, "Transfusion of Blood and Blood Products," last revised 12/20. The policy states in part, "...VI. Documentation A. The patient's Informed Consent must be obtained by a LIP (Licensed Independent Practitioner) and documented on [form numbers] prior to blood administration except in emergencies."

A review was conducted of the training file for RN #1. RN #1 completed annual "Blood Administration Competency" training on 02/14/23.

A review was conducted of the training file for RN #2. RN #2 completed "Super-User Blood Administration Competency" on 02/08/23, and "Annual Blood Administration" on 10/02/22.

An interview was conducted with the Clinical Coordinator of the ED on 02/15/23 at 3:09 p.m. The Clinical Coordinator verified patient #1 received platelets on 01/01/23. No consent was present in the electronic medical record (EMR).

An interview was conducted with RN #1 on 02/15/23 at 3:15 p.m. Regarding blood administration, RN #1 states, "We make sure there is a consent and it is signed by the physician. We get a witness for the consent, and we put it in the folder at the charge desk. It will be scanned in the medical record." Regarding patient #1, RN #1 states, "The consent would have been signed by [physician #1] and a family member or the patient themselves, I'm not sure. I don't remember what I did with the consent."

An interview was conducted with RN #2 on 02/15/23 at 3:34 p.m. RN #2 did not remember patient #1. Regarding blood transfusions, RN #2 states, "I was witness to this platelet administration according to the paperwork. We witness the consent, then we verify the patient's name, date of birth, wristband, the blood product, the type of product, the numbers, the expiration dates, the medical record number, the volume and the number of units. We help get the pre vitals while the other nurse is setting up the tubing. Normally, the doctors do the consent with the primary nurse. After everything is verified, the paper goes to the paper chart, and then it is placed in a bin to be scanned into the computer. Medical records just take the papers and they scan them in. In this case I do remember that we had tried to use the bridge to do the proper blood documentation, but the password wouldn't work so we used the paper. I don't remember anything else."

An interview was conducted with Physician #1 on 02/16/23 at 8:30 a.m. Regarding patient #1 consent for platelets, Physician #1 states, "Usually the nurses will call if there is no consent to get one completed."

An interview was conducted with the Health Information Management (HIM) technician (tech )#1 and #2 on 02/16/23 at 11:04 a.m. Regarding the process of obtaining and scanning paper records from the units, HIM tech #1 and #2 states, "We pick up the papers all week. Sometimes they come down with no patient stickers. We always place a note on top of the pile of papers from where they came from, so we can send them back to the floor for a sticker If there is no sticker. We return these to the floor in an envelope the next morning when we come to pick up more papers. We lay them at the nurse's desk and tell him it needs a sticker. Within a few hours of picking any document up it gets scanned. Any documents sent to us with the sticker on them would be scanned into the medical record."

An interview was conducted with the Regulatory Coordinator on 02/16/23 at 8:15 a.m. The Regulatory Coordinator verified there was no consent for platelet administration in the patient's medical record.