HospitalInspections.org

Based on review of policy and procedure, staff interview and review of complaints and grievances, this hospital failed to address 2 of 2 out of a total of 4 grievances (Patient #1 and #14) reviewed, in writing to the complainant as part of its resolution process.

Findings include:

The hospital's policy titled, "Patient Satisfaction/Complaint and Grievance/Service Recovery," dated August 2008, does not distinguish between complaints and grievances in accordance with the Federal Conditions of Participation.

The hospital's complaint management steps on page 3 of 4 of the policy, A. 1. are as follows: "1. The on-one Complaint Management Record is utilized. 2. The hospital employee attempts to resolve the complaint and inform the family of the resolution. 3. If the employee is unable to resolve the issue, it is referred to their supervisor/director or appropriate ancillary department. The employee gives the customer the name of department or staff person who will respond. 4. Complaints are logged and trended by each department and communicated to department staff and QRC [unknown abbreviation] staff for the purpose of hospital-wide trending and identification of process improvement opportunities."

In area B. the policy states, "If the complaint cannot be resolved or the customer requests additional follow up the grievance process is initiated."

During a discussion with Chief Nursing Officer (CNO) A on 3/9/10 at 10:45 a.m., CNO A agreed that the hospital's delineation between complaints and grievances do not coincide with the Centers for Medicare and Medicaid Services (CMS).

Hospital policy titled, "Patient Satisfaction/Complaint and Grievance/Service Recovery" dated August 2008 states on page 4 of 4, IV. D. "Upon completion of the grievance evaluation, the patient is given a written notice of the outcome."

Per Risk Manager B, on 3/8/10 at 3:37 p.m., B states, "We are not consistent in doing this."

In review of Patient #1's complaint documented by the hospital on 1/28/10, Patient #1 complained to nursing staff, supervisory staff, and the Director of the floor she was a patient on. The complaint documentation indicates Patient #1 was satisfied with the resolution of the complaints after speaking to Director A on 1/28/10.

Per interview with Assistant Administrator H on 3/9/10 at 10:47 a.m., a few days after Patient #1 was discharged from the hospital, Assistant Administrator H contacted her by phone and had a conversation regarding the same complaints, however this is not part of the complaint documentation.

On 2/22/10 the hospital received a satisfaction survey from Patient #1 outlining the same complaints in writing.

Patient #1 did not receive a written response from the hospital regarding its investigation, actions, or resolution. This is confirmed by Risk Manager B on 3/8/10 at 3:37 p.m.

Patient #14 was discharged from the hospital on 10/20/09, and on 10/21/09 a phone call was placed to the home per request of Patient #14's family by Director M. Patient #14's family relayed several complaints related to the quality of his care. Director M discussed these issues with the staff.

There is no indication that Patient #14 received a written response regarding the grievance resolution. This is confirmed by Risk Manager B on 3/8/10 at 3:37 p.m.

Based on medical record review, policy and procedure review, and staff interview, this hospital failed to ensure that patient's pain management was appropriately assessed and reassessed according to hospital policy and guidelines in 8 out of 10 medical records reviewed (Patients #1, 2, 3, 4, 5, 7, 9, and 10).

Findings include:

Hospital policy titled, "Pain Management," with an effective date of April 2008 states on page 2. "Health Care Professional's Responsibilities for Pain Management, 1. Patients are assessed for pain using a 0-10 scale or appropriate alternative tool for objective measurement. 2. Assessment of any report of pain includes intensity, location, onset, a visual or physical assessment of the pain site, and the present pain management regimen. 3. Patients are asked what their acceptable level of pain is (comfort goal)."

In the same policy under the section titled, "Ongoing Assessment/Treatment", the policy states in #2. "After any pain management intervention, pain scores are reassessed within one hour. 3. Any patient with pain scores greater than their acceptable level in two subsequent assessments is to have the pain control plan of care modified and pain reassessed every 2 hours until pain is acceptable."

A hospital flow sheet, titled, "Adult Pain/Fall Risk Flow Sheet," with guidelines for use, was developed to be used by nursing for patient pain assessment. This form was revised in 11/09.

Per an interview with the Chief Nursing Officer (CNO) A on 3/9/10 at 10:45 a.m., it is the expectation that pain assessments and reassessments be documented on the pain assessment flow sheet.

A medical record review was completed on Patient #1's closed medical record on 3/9/10 at 6:30 a.m. Patient #1 had back surgery on 1/26/10 and arrived to the post operative floor approximately 8:00 p.m. The only entry on the pain assessment flow sheet on this date was at 8:00 p.m. with a reassessment at 9:00 p.m.

On 1/28/10 there are entries for 3:20 a.m., 7:30 a.m., and 4:00 p.m.. Patient #1's pain intensity rating is higher than her acceptable pain rating on all 3 occasions, and there is no reassessment of pain within one hour for the 7:30 a.m. and 4:00 p.m. entries. Patient #1's pain was not reassessed every 2 hours.

On 1/29/10 there are 3 entries for pain assessment (12:45 a.m., 7:50 a.m., and 8:30 p.m.). Patient #1 rated her pain higher than her acceptable level on all 3 occasions, on two occasions the pain was reassessed but a numerical value was not entered for the pain rating. Patient #1's pain was not reassessed every 2 hours.

On 1/30/10 Patient #1 was given two pain pills at 1:15 a.m., however there is no coinciding pain assessment. Pain was reassessed at 3:15 a.m, it is rated as 8 with an acceptable level of 0, there is no documented reassessment. At 8:10 a.m. pain is rated as "ok", this is not an acceptable entry for a numeric pain scale. Pain reassessment was done at 9:10 a.m., but entered late on the flow sheet and not indicated as a late entry. After a pain reassessment at 10:10 a.m. here is not another documented assessment until 4:35 p.m. Patient #1's pain was not assessed every 2 hours.

A medical record review was completed on Patient #2's closed medical record on 3/8/10 at 1:00 p.m. Patient #2 was admitted to the hospital on 3/4/10 for a fusion of the spinal bones in his neck. Patient #2 was discharged on 3/7/10.

Between 3/4/10 at 9:00 p.m. and discharge on 3/7/10, there are 3 missed pain reassessment entries. Despite Patient #2's pain not being at an acceptable level for 2 consecutive assessment periods on 5 occasions, his pain was not reassessed every 2 hours. The pain flow sheet determined to be for 3/4/10 is not dated.

A medical record review was completed on Patient #3's closed medical record on 3/8/10 at 1:30 p.m. Patient #3 was admitted to the hospital on 2/5/10 for surgical intervention for low back pain. Patient #3 was discharged on 2/7/10.

In Patient #3's medical record there is a pain flow sheet that is not dated. There are five entries on the flow sheet for pain assessment, all rated pain as "6" with the exception of the 6:30 p.m. entry which lists "8". There are no acceptable pain ratings documented. On 4 of these 5 assessments medication was received. There are no pain reassessments documented.

A medical record review was completed on Patient #4's closed medical record on 3/8/10 at 1:45 p.m. Patient #4 was admitted to the hospital on 1/29/10 for surgical intervention for a herniated disk (rupture of the sack between the bones of the spine). Patient #4 was discharged on 1/31/10.

Between 1/29/10 and 1/31/10 there are 3 entries that are either higher than Patient #4's acceptable level of pain, or that she received intervention for, that are not reassessed. On 1/30/10 there are 3 entries for pain assessment of a post operative patient, 2 rate the pain above her acceptable level. Patient #2 did not get assessed for pain every 2 hours.

On 1/31/10 Patient #4 has 2 entries for pain assessment, one at midnight and one at 7:50 a.m. Pain medication was given at 7:50 a.m. and no reassessment is documented.

A medical record review was completed on Patient #5's closed medical record on 3/8/10 at 2:00 p.m. Patient #5 was admitted on 1/23/10 to the intensive care unit and transferred to the regular post operative floor on 1/26/10 after an accident. Patient #5 was discharged on 1/29/10.

Between 1/26/10 and discharge there are 17 pain assessments completed. There are 3 entries that should have had a reassessment but did not and 2 entries do not rate the pain, either current intensity or acceptable level.

A medical record review was completed on Patient #7's closed medical record on 3/8/10 at 2:45 p.m. Patient #7 was admitted to the hospital on 1/15/10 for surgical intervention for back pain. Patient #7 was discharged on 1/19/10.

Patient #7 was not assessed every 2 hours for pain. There are 5 entries that should have had a pain reassessment but did not.

A medical record review was completed on Patient #9's closed medical record on 3/8/10 at 3:15 p.m. Patient #9 was admitted on 1/7/10 and discharged on 1/8/10 after surgery on her neck for complaints of neck pain and numbness.

There is a pain assessment flow sheet that is undated. On this flow sheet there are two pain assessment entries, the last at 4:00 p.m. Nursing notes dated 1/7/10 at 7:00 p.m. indicate that Patient #9 had some discomfort and an analgesic was given, however neither a complete assessment, or reassessment is done.

A medical record review was completed on Patient #10's closed medical record on 3/8/10 at 3:45 p.m. Patient #10 was admitted on 1/5/10 and discharged on 1/6/10 after surgical intervention for neck and arm pain.

On 1/5/10, there are 5 entries for a pain assessment for Patient #10. Four of these entries required reassessments for pain and only two were completed.

These findings were discussed with and confirmed by CNO A on 3/9/10 at 11:00 a.m.