HospitalInspections.org

Based on interview and record review, the hospital failed to provide promptly a written notice of its decision to 1 of 9 patients (Patient #9).

Findings included:

Patient #9 had a grievance which was received by the hospital on 02/20/19. An acknowledgment letter was sent on 02/27/19 indicating a final response letter which would contain the result of the grievance would be sent in 30-days. There was no evidence that a written notice of the result of the grievance was provided to Patient #9.

In an interview on 03/28/19 at 11:50 AM, Personnel #1 and #2 stated they could not find the said letter since it was with Personnel #3 who was currently out of the hospital. They stated they would provide evidence either on 03/29/19 or 04/01/19. The surveyor talked to Personnel #1 via telephone call on 04/01/19 at 8:45 AM. Personnel #1 informed the surveyor that Personnel #3 would be back to the office on 04/02/19 and would provide the evidence by then if there was one. She stated Personnel #2 and herself could not find the said letter in Personnel #3's office. Personnel #1 stated it is in Personnel #3's computer under her personal drive which they do not have access to. Personnel #3 reports to Personnel #2.

Hospital policy "Patient Grievance Resolution" reviewed 12/10/18 required "4.2.3...c. Once the investigation is completed, the hospital will send a written response to the patient...with the time frames stipulated..."

Based on interview and record review, on 12/18/19 a registered nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) that had issues with BIPAP therapy treatment. This was not documented in Patient #1's medical record (MR).

Findings included:

Patient #1 presented in the emergency department (ED) on 12/18/19 at 4:37 AM and was subsequently admitted for "acute on chronic respiratory failure with hypoxia."

On 12/18/18 at 9:22 AM a physician ordered "BIPAP during night." There was no documentation that a BIPAP treatment was administered.

In an interview on 03/27/19 at 1:45 PM in a conference room, Personnel #4 stated under Respiratory Notes there was no documentation in Patient #1's MR about the attempted BIPAP treatment.

In an interview on 03/27/19 at 2:19 PM via telephone call, Personnel #5 stated she did not document anything when she attempted to administer the BIPAP therapy as per order.

In an interview on 03/28/19 at 10:45 AM, Personnel #6 stated she did not document anything about the attempted BIPAP therapy by Personnel #5. She stated the physician's order for "BIPAP during night" could be administered between 10:00 PM and 12:00 AM. Personnel #6 stated she was present in Patient #1's room when Personnel #5 tried to put on the mask. Patient #1's arms were "flailing." So the Personnel #5 "guided her hand to the side of the bed." Personnel #5 stated the patient was restless and stated she was claustrophobic. The patient refused to be medicated with anti-anxiety medication. Personnel #6 stated Patient #1 ended up with oxygen via nasal cannula.