HospitalInspections.org

Based on document review and interview, the hospital did not follow their policy and procedure for entering a complaint or grievance and therefore failed to provide a response of steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date of completion for 1 patient (P2)(see tag A123), and the hospital failed to follow their policy and procedure for advance directives for 1 of 3 expired patients medical records (MR) reviewed (P2)(see tag A132).

The cumulative effect of these issues resulted in the hospital's inability to ensure that Patient's Rights were promoted at this facility.

Based on document review and interview, the hospital did not follow their policy and procedure for entering a complaint or grievance and therefore failed to provide a response of steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date of completion for 1 patient (P2).

Findings include:

1. Review of policies and procedures (P&P) indicated the following: PolicyStat ID: 2322207, titled Patient Grievance Complaint, Last Approved: 02/2015:
A. A "patient grievance" is a formal or informal written or verbal complaint that is made to the Hospital by a patient, or the patient's representative when a patient issue cannot be resolved promptly. Examples of a patient grievance include: All verbal and written complaints of abuse or neglect.
B. Team Members: Immediately report all complaints of abuse and neglect to the appropriate authorities... The point of contact for patient grievances after discharge is the Service Excellence Manager.
C. Leader: Refer all patient complaints/grievances that cannot be resolved promptly to the Service Excellence Manager and enter into the Midas System.
D. Quality Department: Receives all patient grievances and attempts to resolve patient grievances as soon as possible. Within seven (7) days of receipt..., Quality contacts the patient or patient representative... If the grievance needs further investigation, Quality informs the patient or patient representative of need for further investigation and the expected time frame for resolving the grievance.
i. Documents or updates the patient grievances information in the Midas System.
ii. Provides the complainant with written notice of the hospital's decisions...

2. On 12/1/17 in phone interview beginning at 10:20am C2, family member of patient P2, indicated that he/she had spoke with who he/she believed to be the director of nursing (DON) about issues related to neglect of care for P2 and was told the issues would be looked into. C2 indicated that no response was received so he/she contacted the DON again who indicated having no recollection of the issues/discussion. C2 indicated that he/she had not yet gotten a response from the hospital, that he/she is the POA (power of attorney) for patient P2 and that P2 passed during hospital admission 10/2/17 due to what he/she felt was neglect of care, duties and responsibilities. C2 indicated that he/she could not recall specific dates of when they spoke with hospital administration, but indicated 1 time was during patient hospitalization and the other was after P2's death.

3. Review of complaints and grievances between 9/1/17 and 11/30/17 lacked documentation of a complaint or grievance related to patient P2.

4. On 12/4/17 at approximately 3:00pm A7, Service Excellence Manager, verified lack of documentation of a complaint or grievance related to patient P2. A7 indicated that if someone else took a call with a complaint that was not resolved it should have been sent to him/her and would be documented on the report.

Based on document review and interview, the hospital failed to follow their policy and procedure for advance directives for 1 of 3 expired patients medical records (MR) reviewed (P2).

Findings include:

1. Review of hospital policy Policy ID: 4180301 titled Advance Directive, Last Approved 10/2017, indicated the following: Procedure: Registration Representative - 3. If at the time of registration, it is determined an Advance Directive has been executed, a copy will be made and sent to the floor with the patient's paperwork. An entry is made in the computer indicating the patient has an Advance Directive. Nursing/HCP (health care professional) - 3. Nursing will ask the patient for information and document the content of the Advance Directive stating the patient's wishes in the current medical record, or ask the patient if they wish to execute a new Advance Directive.

2. Review of patient medical records (MR) indicated patient P2 was admitted 10/2/17 for a bladder procedure. The MR Consent for Services and Financial Responsibility form signed by P2 on 9/25/17 indicated the following: 17. Advance Directive Acknowledgment: I have executed an Advance Directive. The MR lacked documentation of an entry indicating the patient had an Advance Directive. The MR lacked documentation of nursing asking the patient for information on the content of the Advance Directive stating the patient's wishes. The MR indicated a CODE 4 (cardiopulmonary Resuscitation) was initiated. The CODE 4 RECORD dated 10/4/17 indicated the following: Time Code Started: 0344. C.P.R. (cardiopulmonary resuscitation) in Progress.

3. Review of hospital incident reports indicated that an event was filed as follows: 10/4/17: Patient found unresponsive...code 4 called. CPR initiated. No order in computer for DNR (do not resuscitate) and no paperwork was found in chart for DNR. When family arrived...stated patient was a DNR and called the POA (power of attorney)...Upon transporting patient and belongings to ICU (intensive care unit), DNR paperwork was found inside patient belonging bag. The report lacked documentation of action taken or a plan of action/correction.

4. On 12/4/17 at approximately 4:00pm A2, Director of Quality, indicated that he/she was not certain what follow up had been done in regards to the event with P2, but would find out and inform. No further information was received prior to exit.

Based on document review and interview, the facility failed to ensure that medical staff (MS) followed facility policy for history and physical (H&P) requirements for 1 of 10 medical records (MR) reviewed (P2).

Findings include:

1. Review of PolicyStat ID: 2316075 titled Medical Records Documentation Requirements, Last Approved: 02/2016, indicated the following: E. Inpatient Medical Records: 1. Documentation of H&P examination completed within the first 24 hours of admission. i. Includes: 1. Chief complaint. 4. Conclusions or impressions. 6. Assessment of the patient's nutritional needs. 7. Reason for admission or treatment. 8. The goals of treatment. 9. Evidence of known advance directives.

2. Review of the MR for patient P2 indicated the patient was admitted to the hospital for a procedure on 10/2/17 and that on 10/2/17 physician MD#1 reviewed an H&P dated 9/12/17. The document/H&P lacked documentation of a chief complaint, conclusions or impressions of the exam, assessment of the patient's nutritional needs, reason for admission or treatment, the goals of treatment and evidence of know advance directives.

3. On 12/4/17 at approximately 3:30pm, A6, Quality Nurse, verified the H&P was not complete as per P&P.

Based on document review and interview, the hospital failed to follow its staffing matrix for 14 of 14 shifts for 1 unit (3NW).

Findings include:

1. Review of the hospital document titled Staffing Matrix - 12 Hours Shifts, approved 2/22/17, indicated that Unit# 614 (3NW) would be staffed as follows: Day - Direct Patient Care: Charge - 1, US (unit secretary) - 1, RN - 3, Tech (nursing technician/assistant) - 2, Total Staff 6.3. Night - Direct Patient Care: Charge - 1, RN - 3, Tech - 2, Total Staff - 5.3. The document also indicated the following: RN (registered nurse) Ratio: Days 1:6. Nights 1:6. Tech Ratio: Days 1:9. Nights 1:9.

2. Review of 1st and 2nd shift staffing sheets for unit 3NW dated 10/1/17 through 10/7/17 as follows, indicated the following staffing assignments:
10/1/17 Shift 7a - 7p: 2 RN/LPN, 1 US "float to All units...", 2 NA (nursing assistant). 0001 Census: (this area was blank) - 13 patient names were noted on the form.
10/1/17 Shift 1900 - 0700: 2 RN/LPN, 1 US (Units): "3SE/3NW/Ortho", 1 NA (nursing assistant) was assigned to "All pts" (patients). 00001 Census: 12.
10/2/17 Shift 7a - 7p: 2 RN/LPN, 1 US "3NW/Ortho", 2 NA. 0001 Census: (this area was blank) - 14 patient names were noted on the form.
10/2/17 Shift 7p - 7a: 2 RN/LPN, US - 0 (this area was blank), 1 NA. 0001 Census: 12.
10/3/17 Shift 7a - 7p: 2 RN/LPN, 1 US "Flt 2SE", 2 NA. 0001 Census: (this area was blank). 15 patient names were noted on the form.
10/3/17 (7p-7a) (form variation noted): 2 RN/LPN, US not identified on the form, 1 NA. Census was not noted on the form, unable to determine patient census.
10/4/17 Shift 7a - 7p: 2 RN/LPN, 1 US "3NW/ortho", 3 NA as follows: 1 "(7A-9A)", 1 "(8:30A - 7P), 1 "(8A - 6P)".0001 Census: (this area was blank) - 16 patient names were noted on the form.
10/4/17 Shift 1900 - 0700: 2 RN/LPN, 1 US "(7p - 8:30p), 1 NA "All pts". 0001 Census: 12.
10/5/17 Shift 7a - 7p: 2 RN/LPN, 1 US "3NW/Ortho", 2 NA (no patient assignment documented). 0001 Census: (a name was written in, but lacked documentation of a number) - 14 patient names were noted on the form.
10/5/17 Shift 1900 - 0700: 2 RN/LPN, 1 US, 2 NA (1 "7-3"/1 "3-7"). 0001 Census: 12.
10/6/17 Shift 7a - 7p: 2 RN/LPN, 1 US "3NW + 3SE", 2 NA. 0001 Census: (this area was blank) - 17 patient names were noted on the form.
10/6/17 Shift 1900 - 0700: 2 RN/LPN, 0 US, 2 NA. 0001 Census: 12.
10/7/17 Shift 7a - 7p: 2 RN/LPN, 1 US "float to help plz", 2 NA. 0001 Census: (this area was blank) - 14 patient names were noted on the form.
10/7/17 (7p - 7a) (form variation noted): 2 RN/LPN, US not identified on the form, 1 NA. Census was not noted on the form.

3. On 12/4/17 at approximately 2:00pm A8, Director of inpatient nursing, indicated the hospital used the Staffing Matrix for staffing the units and did not have a policy for description of use for the matrix or determining patient acuity levels. A8 indicated units, including the 3NW unit, are staffed 1 nurse to 6 patients. A8 indicated that the 1:6 ratio was maintained regardless of patient acuity.

4. Review of the Nursing Complement Data form completed on 12/4/17 by A8 for review date 10/3/17 night shift to 10/4/17 day shift indicated the following:
Night Shift: Direct Patient Care - 2 RN and 1 NA. Indirect Patient Care - 1 RN Nursing Administrator and 1 RN Nursing Educator.
Day shift: Direct Patient Care - 2 RN and 2 NA. Indirect Patient Care - 4 RN Nursing Administrators and 1 RN Nursing Educator

5. On 12/5/17 at approximately 11:30am, A4, Manager, indicated staffing can be a struggle, that on this date there was only 1 US and should have 2. A4 indicated nursing typically staffs 1:6 ratio, but occasionally flag 1:7.

6. On 12/5/17 at approximately 1:30pm A10, Medsurg Manager, indicated staffing sheets for 10/3/17 night shift (1900 - 0700) and 10/7/17 night shift (1900 - 0700) could not be located and he/she documented on the varied forms who was assigned to patient care based on MR review from those dates/shifts.

Based on document review, observation and interview, the nursing staff failed to supervise and evaluate care for 7 of 10 (PA, PB, P1, P2, P3, P4 and P5) patients to assure care was provided in accordance with hospital policy.

Findings include:

1. Review of hospital policies indicated the following:
A. PolicyStat ID: 2395852 titled Documentation Requirements for Active Record, Last Approved: 05/2014: "KBC Charting": Addresses significant changes in patient condition, significant event in treatment, what is occurring as a result of diagnosis, reassessment and enters updates related to nursing diagnosis.
B. PolicyStat ID: 2395919 titled Telemetry Strips - Documentation, Last Approved 11/2013: At beginning of every shift, staff nurse is responsible to review telemetry monitoring on all of his/her patients. Staff nurse will visually analyze rate, rhythm, lead selection and alarm parameters to ensure proper monitoring. Routine rhythm strips are to be saved...every 8 hours. 6 second Strips are to be analyzed and measurements taken with the electronic calipers at the beginning of the 8 hour shift. These routine strips are to be saved...These strips need to be titled "Routine Strip", the first initial and last name with RN/LPN (registered nurse/licensed practical nurse)...and placed in the Nursing Notes section of the medical record (MR). Alarms and arrhythmias will be analyzed...These strips will be "saved events". All pertinent events will be printed and placed in the Nursing Notes.
C. PolicyStat ID: 2395646 titled Fall Prevention, Last Approved: 08/2015:
i. Upon registration all patients, ED (emergency department) and admission to the nursing unit patients are assessed to determine their risk for falls...
ii. IV. The Nurse will assess the patient using the Morse Fall Risk Assessment for their risk to fall...At the beginning of each shift. Due to the typical short length of stays, once a patient is considered a high risk to fall the yellow clasp will remain on the armband, the falls risk alert will remain in the header and falls preventions for high risk will continue through the remainder of the hospital stay. The nurse assessments will continue as outlined...
iii. Morse Fall Score: High Risk = 45 and higher. Moderate Risk = 25-44. Low Risk = 0-24.
iv. Intervention Strategies. Falls Interventions (Observation and Inpatients): Risk level HIGH: Toileting (patient within arms reach of staff).

2. Review of patient MRs indicated the following:
A. Patient PA was admitted 11/29/17 and was a current inpatient. Telemetry monitoring was ordered upon admission. The MR lacked documentation of a telemetry strip for 11/30/17 night shift between 1900 hours and 0700 hours 12/1/17. The MR indicated the patient was a High Fall Risk with a score of 45 on 11/29/17 at 2130 hours. The MR lacked documentation of fall risk shift assessment between 11/30/17 0808 hours and 12/1/17 0750 hours. The MR indicated the patient was up to BSC on 12/1/17 at 0034, 12/2/17 at 1251 and 12/2/17 at 1912 hours. Unable to determine that patient remained within arms reach of staff during toileting.
B. Patient PB was admitted 12/2/17 and was a current inpatient. Telemetry monitoring was ordered 12/2/17 at 1144 hours. The MR lacked documentation of when telemetry was initiated. The earliest dated telemetry strip was dated 12/3/17 at 0708 hours. On 12/3/17 at 1344 hours a Nurse Blue (additional resources for evaluation of a patient with a change in status) called was documented. The MR lacked documentation of a telemetry strip saved prior to or during the time of the event.
C. Patient P1 was admitted 9/14/17 and expired 9/27/17. Telemetry was ordered upon admission 9/14/17 at 1601 hours. The MR lacked documentation of a a telemetry strip from time of the order until 9/15/17 at 0757 hours, lacked documentation of a strip saved for 9/18/17 day and/or night shift. Nursing notes dated 9/18/17 at 0800 indicated the following: Cardiovascular: Cardiac Rhythm: tachycardia. Heart Sounds: Atrial Fibrillation. The MR lacked documentation of a telemetry strip during or near this event time. The MR lacked Morse Falls Risk Assessments for the following shifts 9/15/17 night shift, 9/16/17 day shift and 9/23/17 day shift.
D. Patient P2 was admitted 10/2/17 and expired 10/5/17. Telemetry was ordered following surgery 10/2/17 at 1149 hours and the first strip was saved 10/2/17 at 1915 hours. The MR indicated that on 10/4/17 at 0344 hours the patient was on the BSC (bedside commode), the NA (nursing assistant) noticed on the telemetry monitor, that the patient's heart rate was 20 (beats per minute). The NA responded to telemetry and found the P2 slumped over on the BSC. Nurse Blue was called....patient was unresponsive... The MR lacked documentation of a telemetry monitoring or saved strips between 10/3/17 at 0304 hours and 10/4/17 at 0428 hours and from 10/4/17 at 0810 hours to 10/5/17 at 0703 hours. The MR indicated the patient was a High Fall Risk with a score of 70 on 10/2/17 at 1500 hours and 55 on 10/3/17 at 1900 hours. The MR documentation of 10/4/17 at 0344 hours indicated the patient was not within arms reach of staff during toileting.
E. Patient P3 was admitted 10/19/17 and expired 10/24/17. Telemetry was ordered upon admission 10/19/17. The MR lacked documentation of routine saved telemetry strip(s) between dates/times as follows: 10/19/17 1941 hours and 10/21/17 2059 hours; between 10/23/17 0800 hours and 10/24/17 0822 hours.
F. Patient P4 was admitted 9/9/17 to a telemetry unit and discharged 9/15/17. Telemetry was ordered upon admission 9/9/17. The MR lacked documentation of routine saved telemetry strip(s) between dates/times as follows: 9/9/17 0800 hours and 9/12/17 0755 hours; between 9/12/170755 hours and 9/13/17 0804 hours; and 9/13/17 0804 hours through discharge 9/15/17.
G. Patient P5 was admitted 10/15/17 and discharged 10/17/17. Telemetry was ordered 10/15/17 upon admission. The MR lacked documentation of routine saved telemetry strip(s) between 10/15/17 1858 hours and 10/16/17 at 1845 hours.

3. Observation on 12/4/17 between 10:30am and 12:30pm in the presence of A6, Quality Nurse: At approximately 10:45am it was noted that patient PAs telemetry monitor had been alarming with unrecognizable readings for approximately 5 minutes. Upon question for explanation of what the monitor was doing, manager A4 went to room and indicated the leads needed changed. At approximately 11:30am it was noted that the monitor for patient PA continued to alarm with no staff tending to the alarm. Asked A5 US, unit secretary, if he/she knew what was going on and if a nurse should be contacted. A5 indicated the patient must be throwing up or something, then went to check. Upon return indicated no, patient PA was just lying there. A5 then indicated unit must need changed, took another telemetry unit to the patient's room and reconnected.

4. On 12/4/17 at approximately 12:15pm patient PA indicated that at times he/she does have to wait quite a while for the call light to be answered. Stated it's about 50/50 on times to get a timely response. PA indicated that staff assist him/her up to the bathroom, but that he/she is left alone when toileting. PA indicated that he/she is not aware of being on any type of fall protocol. PA stated that last night his/her heart monitor fell out of his/her pocket, hit his/her foot real hard causing soreness and bruising, then hit the floor. PA indicated the heart monitor was not changed after the incident.

5. On 12/4/17 between 10:30am and 12:30pm A6 indicated telemetry strips are to be added to the MR at least 1 time every shift and for any abnormal readings. A6 verified lack of documentation of telemetry strips for patients PA and PB as indicated in MR review. On 12/4/17 at approximately 6:00pm A6 verified lack of documentation of telemetry strips and toileting assistance per policy for patients P1, P2, P3, P4 and P5. On 12/5/17 at approximately 12:20pm A6 verified MR reviews with missing telemetry strips and toileting assistance.