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Based on the systemic and serious nature of the standard level deficiencies related to patient rights, the facility staff failed to substantially comply with this Condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

CFR 482.13(a)(2)(iii) Tag 0123
The information reviewed during the survey provided evidence that the facility failed to provide a follow up grievance letter as per facility policy for one of five applicable medical records with grievances reviewed (MR11).

CFR 482.13(c)(2) Tag 0144
The information reviewed during the survey provided evidence that the facility failed to promote patient's right to care in a safe setting by failure to document emergency room nursing reassessments in accordance with the facility guidelines in two (2) of 18 MRs reviewed (MR1 and MR4); and failure to document pain reassessments in accordance with facility guidelines and policy in three (3) of 18 medical records reviewed (MR4, MR7 and MR10).



Cross reference:
482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision
482.13(c)(2) Patient Rights- Care in Safe Setting

Based on review of facility documents, medical records, and staff interview (EMP), it was determined the facility failed to provide a written response within 30 days from receipt of a grievance for one of five applicable medical records with grievances reviewed (MR11).

Review on October 11, 2024, of the facility policy "Rights and Responsibilities - Patients (#86) " last reviewed by the facility on February 28, 2024, revealed: "I. Purpose St. Luke ' s University Health Network supports a Patients ' Bill of Rights and Responsibilities, believing that observance of these rights and responsibilities will contribute to more effective patient care and greater satisfaction for patients...III. Procedure ... 34. The patient has the right to register a grievance through Administration ...."

Review on October 10, 2024, of the facility policy " Complaint and Grievance Resolution (#2)," last reviewed December 2023, revealed "I. Purpose: St. Luke's University Health Network supports the rights of all patients and/or their representatives to express dissatisfaction regarding their hospital experience and to seek resolution of their concerns.... C. Management of a Patient Grievance. 1. The person receiving the patient grievance will complete Part A of the Complaint and Grievance Tracking Form....3. The person receiving the patient grievance will notify the Manager or designee of the area named in the complaint as soon as reasonably practical... 5. The Manager of the area named in the complaint will coordinate the effort to investigate, respond, and complete Part B of the Complaint and Grievance Tracking Form.... 6. The Manager of the area named in the patient grievance will: Contact the complainant ... The Manager will provide their contact information and establish a mutually agreeable time frame for providing a resolution. Initial contact and the investigation of a patient grievance should occur within 24 hours, or the next business day... 7. On average, it is expected that most patient grievances will be resolved within 7 days of receipt. For situations where additional time is needed, the patient or their representative will be notified of the continued follow-up efforts and reassured that a written response will be provided within a stated number of days, but no more than 30 days from receipt of the grievance."

Review on October 10, 2024, of the facility ' s complaint and grievance log revealed a grievance related to MR11. This grievance was reported to the facility via a phone call on April 9, 2024, and was documented on the Complaint and Grievance Tracking Form. There was no documentation of a written response provided to MR11.

Interview with EMP2 on October 10, 2024, at approximately 1400 confirmed a Complaint and Grievance Tracking Form was completed for MR11 and there was no documentation present of MR11 receiving a written response to the grievance.

Interview with EMP4 on October 11, 2024, at 0934 confirmed there was no written response to the grievance found for MR11.

Based on review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to document emergency room nursing reassessments in accordance with the facility guidelines in two (2) of 18 MRs reviewed (MR1 and MR4); and the facility failed to document pain reassessments in accordance with facility policies in three (3) of 18 medical records reviewed. (MR4, MR7 and MR10)

Findings include:

1. Review on October 10, 2024, of the facility policy "ED [Emergency Department] Documentation Guidelines," last updated October 2023, revealed "Vital signs: all patients must have a full set of vital signs, regardless of age. Vital signs are defined as: Blood Pressure, Heart Rate, Respirations, Pulse Oximetry, Pain Scale, Temperature ... Frequency of vital sign depends on acuity level " The ED documentation guidelines contained a grid with frequency of vital signs dependent on Emergency Severity Index (ESI). ESI 1 equals highest triage level and ESI 5 lowest triage level. The ESI is a nationally recognized standard for evaluation and triage of emergency department patients. "ESI 1 Q" [every] "1 HR" [hour] ", ESI 2 Q 1 HR, ESI 3 Q 2 HR, ESI 4 Triage/DC [discharge], ESI 5 Triage/DC ... A change in patient status requires documented vital signs as needed ... "

Review on October 11, 2024, of the facility policy, "Rights and Responsibilities - Patients (#86)" last reviewed on February 28, 2024, revealed: " 18. The patient has the right to expect good management techniques to be implemented within St. Luke ' s University Health Network acute care facilities ..."

Review of MR1 on October 10, 2024, at approximately 1345 revealed the patient arrived at the ED on September 12, 2024, at 1826. Documentation revealed MR1 was assigned an ESI level of 3. The initial nursing assessment occurred on September 12, 2024, at 1843. There was no documentation of a nursing reassessment on September 12, 2024, at 2043.

Review of MR4 on October 10, 2024, at approximately 1445 and on October 11, 2024, at 0950 revealed the patient arrived at the ED on September 30, 2024, at 1049. Documentation revealed MR4 was assigned an ESI level of 3. The initial nursing assessment occurred on September 12, 2024, at 1058. There was no documentation of nursing reassessment on October 1, 2024, at 0400.

Interview with EMP7 on October 10 - 11, 2024, confirmed the findings noted above in MR1 and MR4.

2. Review on October 10, 2024, of the facility policy "ED [Emergency Department] Documentation Guidelines," last updated October 2023, revealed "Vital signs: all patients must have a full set of vital signs, regardless of age. Vital signs are defined as: Blood Pressure, Heart Rate, Respirations, Pulse Oximetry, Pain Scale, Temperature ... Pain documentation: Pain scale should be documented upon arrival ... and post intervention ... "

Review on October 11, 2024, of the facility policy "Pain Management," last revised September 2024, revealed: " ... IV. Procedure A. ... 4. As appropriate, when pain has been identified and responded to, patients will be reassessed for effectiveness of medications and/or complementary pain relief methods ... C. If pain is present, the following should be assessed: 1. Pain score a. To assure consistency the following pain intensity rating will be utilized: i. 0 (No pain) ii. 1-3 (Mild pain) iii. 4-6 (Moderate pain) iv. 7-10 (Severe pain) ... F. Assess the patient's response to pain intervention within an appropriate timeframe ..."

Review on October 11, 2024, of the facility policy "Rights and Responsibilities - Patients, " last reviewed on February 28, 2024, revealed: " ... III. Procedure ... 18. The patient has the right to expect good management techniques to be implemented within St. Luke's University Health Network acute care facilities/ambulatory surgery facilities considering effective use of time of the patient and to avoid the personal discomfort of the patient. ... 27. All patients have the right to have their pain assessed and managed when they are admitted and throughout their hospitalization ... "

Interview with EMP7 on October 10, 2024, at approximately 1415 related the expectation for reassessment of pain after interventions given would be within 10-40 minutes for IV medication and within 30-90 minutes for p.o. (oral medication).

Review of MR4 on October 10, 2024, at approximately 1445 and continued on October 11, 2024, at 0950 revealed the patient arrived in the ED on September 30, 2024, at 1049. The patient was assigned an Emergency Severity Index (ESI) level of 3. The initial nursing assessment on September 12, 2024, at 1058 revealed a pain level of 8 on October 1, 2024, at 0650. An intravenous (IV) opioid pain medication of morphine 2 mg IV was given on October 1, 2024, at 0650. An IV antianxiety medication of Ativan was given at 0750. There was no pain reassessment documented post intervention with the vital signs on October 1, 2024, at 0800. Vital signs were reassessed on October 1, 2024, at 0930 with a pain level of 10. IV morphine 2 mg was given on October 1, 2024, at 0944. Vital signs were reassessed on October 1, 2024, at 1000. There was no pain level documented post intervention. Vital signs were reassessed on October 1, 2024, at 1200. There was no pain level documented. IV morphine 2 mg was given on October 1, 2024, at 1317 for a pain level 10. Vital signs were reassessed on October 1, 2024, at 1422 and 1430 with no pain level documented post intervention. IV morphine 2 mg was given for a pain level of 10 on October 1, 2024, at 1621. Pain reassessment on October 1, 2024, at 1636 remained at a pain level of 10. There was no documentation the provider was notified. Vital signs were reassessed on October 1, 2024, at 1730 with no pain level documented. On October 1, 2024, at 1920 the attending was at the bedside assessing the patient. On October 1, 2024, at 1957 vital signs were reassessed. The patient was restless and unable to follow commands. On October 1, 2024, at 2010 IV Ketamine (a non-narcotic sedative) 12 mg was given per physician order. Vital signs were reassessed at 2057 and 2105. There was no documentation of the pain levels or sedation levels.

Review of MR7 on October 11, 2024, at approximately 1115 revealed the patient arrived to the ED on September 30, 2024, at 1033. ESI level was 3. A pain level of 4 was documented on September 30, 2024, at 1354. IV Dilaudid 0.4 mg an opioid pain medication was given on September 30, 2024, at 1545. Vital signs were reassessed at 1615 on September 30, 2024, which did not include the pain level. IV morphine 6 mg an opioid pain medication was given at 1651 on September 30, 2024. Vital signs were reassessed at 1700, 1730, 1800, 1930, 2030, 2100, 2130 on September 30, 2024. There were no pain levels documented.

Review of MR10 on October 11, 2024, at approximately 1215 revealed the patient arrived to the ED on September 17, 2024, at 2151. ESI level was 3. A pain level of 7 was documented on September 18, 2024, 0131. Vital signs were reassessed at 0159 and 0215 on September 18, 2024. There were no pain levels documented.

Interview with EMP7 on October 10-11, 2024, confirmed the findings noted above in MR4 at time of the MR review.

Interview with EMP3 on October 11, 2024, confirmed the findings noted above in MR7 and MR10 at the time of the MR reviews.