HospitalInspections.org

Bases on interview, review of grievance/complaint files and other documents, it was determined the facility failed to ensure prompt investigation of grievances. This finding was noted in 6 of 8 grievance files reviewed (File #s 5 through 10).

Findings include:

Grievance File #5 was received on 3/25/15 and resolved in 16 days, on 4/10/15.

Grievance File #6 was received on 3/26/15 and resolved in 19 days, on 4/14/15.

Grievance File #7 was received on 3/27/15, an acknowledgement letter was sent to the complainant on 3/30/15. As of 4/14/15, 18 days after the receipt of the grievance, the resolution of the grievance was incomplete.

Grievance File #8 was received on 3/30/15 and resolved in 11 days, on 4/10/15.

Grievance File #9 was received on 3/30/15. The review of the file on 4/14/15 revealed the grievance had not been resolved after 15 days of receipt and there was no acknowledgement of this grievance by the facility.

Grievance File #10 was received on 4/3/15 and acknowledged on 4/10/15. On 4/14/15, it was noted the grievance has not been resolved 11 days after receipt.

The hospital policy titled "Complaints/Grievances - Patient/Family/Significant other " revised on 3/15/15 notes "Grievances and complaints from Inpatient areas, Hemodialysis, and the Emergency Department will be referred to Patient Relations, investigated in consultation with the Executive Grievance Committee, and responded to within 7 days. If the investigation will take longer than the aforementioned 7 days, an acknowledgement letter will be sent to the grievant within 5 business days of receipt of the complaint. The letter will acknowledge our receipt of the grievance and give an expected response date not to exceed 21 days from our receipt of the grievance".

At interview with Staff #1 on 4/14/15 at approximately 1:00 PM, he stated the Complaint/Grievance policy was recently revised in March 2015 and he is working with hospital staff to improve the turnaround time to ensure most of the grievances are promptly investigated and resolved.

It was observed that 6 out of 8 grievances received in March 2015 exceeded the 7 days resolution timeframe established by the facility. Seventy five percent (75%) were deferred to the 21 days turnaround time for resolution of grievances. Note: Grievance file #s 1, 2, 3 and 4 were received in March, but before 03/20/15, as such they were removed from the sample considering that the last revised date of the Hospital's Complainants/Grievances policy was 03/15/15.

Based on interview and observation, it was determined the facility failed to ensure the psychiatric unit is safe and free of hazards for individuals with suicidal, psychotic, and self-injurious behavior. Specifically, bathrooms in the psychiatric unit are fitted with Paper Towel, Toilet Paper, and Soap Dispensers that are looping hazards. This finding was noted in fifteen of fifteen patients' rooms in the psychiatric unit.

Findings include:

During tour of the Inpatient Psychiatric Unit on 4/14/15 at about 11:20 PM, it was observed that each room's bathroom has a Paper Towel Dispenser (13 inches length x 13 inches width x 8 inches depth) that is fitted to the wall approximately 54 inches from the floor. The Toilet Paper Dispenser (14 inches x 5¼ inches x 7 inches depth) is 27 inches above ground and the Soap Dispenser (9 ½ inches x 5 inches x 4 inches depth) is fitted to the wall 55 inches above the ground.

At interview with staff #8, she stated, "the facility is in the process of replacing the bathroom fixtures to those recommended by the Office of Mental Health.

Based on interview, review of Grievance/Complaint committee minutes and other documents, the facility failed to track the timeliness of grievance resolution and implement actions necessary to correct identified problems. This finding was noted in monthly grievance/complaint data from October 2014 to March 2015.

Findings include:

The review of Grievance committee minutes for October 2014 to March 2015 noted each month's grievances/complaints received are categorized and tallied. The Performance Improvement and Patient Safety Program Committee (PIPSP) minutes for October 2014, December 2014, January 2015, and April 2015 revealed the committee reviewed a sample of the previous month's grievances. It was noted that the proposed action and recommendation of the PIPSP for the selected cases reviewed were focused on the outcome and closure of the complaint. The Performance Improvement Program failed to: show the tracking of the timeliness of grievance resolution; analyze IT data to identify problems concerning patient care; develop proposed courses of action; and implement actions necessary to correct the identified problems.

At interview with Staff #3 on 4/14/15 at 11:00 AM, he stated that timeliness of resolution of grievances/complaints was not being tracked and trended. He stated the PIPSP committee reviews all grievances and proposed action and outcomes are discussed and documented in the committee minutes. Staff #3 states that tracking and trending of Grievances/complaints is a good idea and would be considered


27378

Based on interviews, review of medical records and other documents, the facility failed to ensure the medical treatment provided to Patient #1 met accepted standards of medical practice. Specifically, the facility failed to provide adequate monitoring and prompt intervention for Patient #1 who was diagnosed with angioedema (the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues) secondary to severe allergic reaction to contrast medium. This finding was note in 1 of 10 records reviewed (Patient #1).

Findings include:

Medical Record #1 (MR #1) is a 59-year-old female who arrived to the Emergency Department (ED) by ambulance on 6/19/14 at 8:50 PM with a chief complaint allergic reaction. Patient's medical history included End Stage Renal Disease on hemodialysis, hyperkalemia (the condition in which the concentration of the electrolyte potassium in the blood is elevated), Diabetes Mellitus, hypertension and renal disorder. The triage note at 8:50 PM indicated the patient received Benadryl 50 milligrams (mg) prior to arrival in the Emergency Department (ED) on 6/19/14.

ED physician on 6/19/14 at 9:00 PM notes, an alert patient, oriented to place person and time. He notes the patient appeared distressed, with swollen tongue, swollen eyelids, and face. The patient was positive for wheezes, no rash noted, and no erythema (redness of the skin or mucous membranes, caused by the increase of blood flow to different tissues or superficial capillaries in the body). Pulse oximetry was 98%. Medications given to the patient included Ipratropium (Atrovent) 0.5 mg/2.5 milliliter (ml) nebulizer treatment at 10:17 PM and at 10:18 PM, Albuterol nebulizer treatment 2.5 mg/3 ml, Benadryl injection 50 mg, and Methylprednisolone injection 125 mg were administered. The patient was placed on cardiac monitor, labs drawn and respiratory status monitored. The physician impression was angioedema of unknown etiology. On 6/20/14 at 00:54 AM, the patient was admitted to Medical Intensive Care Unit (MICU) for further management and was awaiting bed placement.

The facility's policy titled Admitted patient in the Emergency Department last revised 11/2008 notes the medical staff assigned to the admitting service are responsible for the clinical management of admitted patient in the ED, including admission work up and treatment, diagnostic testing and medication orders. However, when an Emergency arises, the Emergency Department Attending Physician will manage the emergent condition until the admitting team arrives in the department.

The care of patient #1 after she was admitted, failed to demonstrate continuous evaluation and prompt intervention for abnormal laboratory values and radiology findings.

The admitting History and Physical completed by resident physician on 6/20/14 at 4:23 AM, notes a plan for continuous pulse oximetry with oxygen at 2 liters (L) via nasal cannula. An order was written by the resident physician at 4:22 PM for vital signs every 15 minutes. The patient's record lacked documentation of vital signs as ordered; There was no vital signs and pulse oximetry readings after the last recorded vital signs and pulse oximetry reading on 6/20/14 at 7:46 AM.

On 6/20/14 at 1106, the admitting attending, notes the patient was seen and case discussed on rounds with house staff, he notes, "clinical and overnight issues noted, laboratory data and radiographs reviewed. The patient on examination was awake feels better but still with dysphagia, no stridor, no active wheezing". The impression was Angioedema with unclear etiology. The physician documented a plan for close monitoring of airway.

Although x-ray of neck soft tissue ordered on 6/20/14 at 10:58 AM, with results at 11:59 AM, revealed marked prevertebral soft tissue swelling and Ipratropium (Atrovent) 0.5 mg/2.5 ml nebulizer treatment and Benadryl injection 50 mg were administered at 12:09 PM, there was no documentation of continuous assessment of the patient's airway.

Based on the findings of x-ray of neck soft tissue, computed tomography (CT) scan was suggested for further evaluation. An order was placed for CT scan Soft Tissue Neck without contrast at 1:41 PM as well as venous blood gas and arterial blood gas. CT scan was not done and there was no prompt intervention for a critical laboratory value for the partial pressure of oxygen (pO2) in the pulmonary alveoli which was: 27.3 millimeters of Mercury (mmHg) [Acceptable Range: 80.0 to 110.0 mmHg] and Oxygen (O2) saturation: 49.9% (Acceptable Range: 96.0 to 99.0%) reported at 2:46 PM.

A late note by Nephrology attending timed 4:20 PM revealed an assessment of the patient after the critical lab value was reported at 2:46 PM. The physician notes breath sounds were normal, no stridor, no respiratory distress, no wheezes, and no rales. The physician impression was anaphylactic reaction. He notes etiology is possibly related to the use of fluoroscopy material during the Arteriovenous fistula thrombectomy (removal of blood clot). The physician agreed with the continued use of steroids and H-blockers (agents that block the action of histamine by competitive binding to the H1 and H2 receptor). He notes, "consider evaluation for mechanical ventilation; ABG" (arterial blood gas) "with PaO2" (low arterial oxygen) "and O2 saturation."

An addendum written by the admitting physician at 1500 indicated an evaluation of the patient and the review of x-ray that shows significant narrowing of upper airway, soft tissue neck mass versus abscess. There was no indication that mechanical ventilation was immediately considered. The patient received Methylprednisolone 125 mg intravenously at 13:06 PM.

Consequently, at 3:19 PM, the patient was coded, two attempts at intubation failed, Endotracheal Tube was successfully placed at 3:22 PM. The patient was pronounced dead at 3:45 PM.

At interview with Staff #2, ED Chair and Staff #3, Chief Medical Officer on 4/14/15 at 10:22 AM, they reported the patient had no indication for intubation on presentation to the ED on 6/19/14 at 8:50 PM. The patient received bronchodilators, steroids, H-blockers with good effect and was saturating well between 98-100%. Staff #2 stated the patient was admitted on 6/20/14 at 0054 and her care was directed by admitting physicians, nursing care however was accomplished by ED nurses. Staff #2 stated that three attending physicians evaluated the patient during the course of admission; the patient did not exhibit signs of respiratory distress and they all concurred with the treatment plan for management with steroids, bronchodilators, and H- blockers.

Staff #3, when asked about the lack of timely intervention for abnormal laboratory values for arterial blood gas and lactic acid, stated the arterial blood gas reports on 6/20/14 at 6:00 AM, and 2:28 PM were consistent with venous blood values. He reported the patient was saturating well and had no indication for intubation. Staff #2 stated that Lactic acid is an isolated marker and could provide valuable information if trended. Staff #2 and #3 both acknowledged that the medical record lacked evidence of vital signs and oxygen saturation monitoring in accordance with physician orders.

Based on interviews, review of medical records and other documents, it was determined that nursing services failed to ensure patients' nursing care needs are furnished in accordance with facility's policy and physicians' written orders.

See Tag - A 396

16401

Based on interviews, the review of medical records and other documents, it was determined that nursing staff failed to ensure 1) patients' care needs are assessed and physician orders are implemented; and 2) the implementation of facility's policy for the prevention and treatment of pressure ulcers. These findings are noted in 5 of 20 records reviewed (Patient #1, #2, #3, #4, and #5).

Findings include:

1) Patient #1 is a 59-year-old female who was evaluated in the Emergency Department (ED) on 6/19/14 for complaint of severe allergic reaction. The patient was admitted with diagnosis of Angioedema (the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues) and was awaiting bed placement in the Medical Intensive Care Unit.

The patient's admitting History and Physical completed by resident physician on 6/20/14 at 4:23 AM, notes a plan for continuous pulse oximetry with oxygen at 2 liters (L) via nasal cannula. An order was written by the resident physician on 6/20/14 at 4:22 PM for vital signs every 15 minutes. In addition, the admitting attending on 6/20/14 at 11:06 AM notes the patient on examination was awake feels better, but still with dysphagia, no stridor, no active wheezing. The physician documented a plan of care that includes close monitoring of the patient's airway.

The patient's record lacked documentation of vital signs as ordered. There was no vital signs and pulse oximetry readings after the last recorded vital signs and pulse oximetry reading on 6/20/14 at 7:46 AM. Consequently, the patient went into cardiac arrest on 6/20/14 at 3:19 PM.

At interview with Staff #2 and Staff #3 on 4/14/15 at 10:22 AM, they stated the medical record lacked evidence of vital signs and oxygen saturation monitoring in accordance with physician orders.


Physician orders written on 7/1/14 for daily treatment of Patient #5's sacral ulcer with Collagenase ointment was not consistently implemented. The review of treatment record indicated dressing change with Collagenase (enzymatic debriding agent) ointment was not implemented on 7/2, 7/7, 7/9, 7/14 and 7/18/2014. On 7/2, 7/7 and 7/14, nurse noted patient was transferred to a procedural area; however, there was no indication the patient received the daily pressure ulcer treatment on her return to the unit.

At interview with Staff #7 on 4/13/15 at 11:45 AM, she stated Patient #4 had a history of End Stage Renal Disease and was on hemodialysis treatment three times weekly. She stated the patient's daily treatment with Collagenase ointment could have been omitted because patient was out of the unit for hemodialysis treatment when the daily pressure ulcer treatment was due.


2) Patient #5, a 59-year-old with multiple medical conditions was admitted on 5/6/2014 for treatment of multiple organs system failure. On 5/14/14, a stage II, 3 centimeter (cm) x 2 cm sacral ulcer was identified that progressed to a black, non-healing, and unstagable 8 centimeter (cm) x 6 cm x 3 cm ulcer by 8/6/14.

The facility's policy for Pressure Ulcer Prevention and Management notes that each patient with pressure ulcer would have a weekly progress reassessment that includes documentation of pressure ulcer location, size, stage, and character.

The weekly progress reassessment of patient's sacral ulcer was documented only three times, on 5/14/14, 5/23/14, and 8/6/14. There were twelve weeks of missing weekly progress reassessments between 5/14/14 and 8/6/14.

At interview with Staff #7 on 4/13/15 at 12:15 PM, she stated the weekly comprehensive skin assessment is done every Wednesday for patients with impaired skin integrity. She acknowledged the skin assessment was not consistently documented for Patient #5.


Review of medical record for Patient #2 noted the patient was admitted on 11/20/14 with an intact skin documented by the admitting nurse on 11/20/14 at 8:14 AM. Prior to 01/07/15 there was no evidence documented that Patient #2 started to or had developed a pressure ulcer. On 01/07/15, nursing documentation noted a stage II pressure ulcer to the right sacrum, pink in color measuring 5 centimeters (cm) x 7 cm x 0.1 cm. The mobility flow sheets dated 1/6/15, 1/7/15 and 1/8/15 failed to indicate the patient was consistently turned and positioned every two hours as per facility's policy.


Review of medical record for Patient #3 on 4/9/15 noted this patient was admitted on 4/6/15 with complaint of fever and malodorous bilateral feet ulcers. The past medical history is significant for dementia, Tuberculosis, Diabetes Mellitus, Hypertension, Renal disorder, cancer-colon. The initial nursing assessment on 4/6/15 assigned Patient #3 a Braden score (a scale for predicting pressure ulcer risk) of less than 18 (there is a possible 23 points - Very High Risk: Total Score 9 or less; High Risk: Total Score 10-12; Moderate Risk: Total Score 13-14; Mild Risk: Total Score 15-18; and No Risk: Total Score 19-23).

The review of the facility's policy titled "Pressure Ulcer Prevention and Management" last reviewed 2/2012, notes nursing responsibilities include, "Assess patient on admission using the Braden Scale found in the Nursing Database. If the Braden total score is 18 or less, implement the Prevention Care Plan. If a pressure ulcer is present on admission or the patient develops a pressure ulcer while in the hospital, continue the Prevention Care Plan and initiate the Treatment Care Plan. Both plans include repositioning the patient at two hours intervals".

Mobility flow sheets for 4/7/15 and 4/8/15 failed to indicate the patient was being turned and positioned every two hours as per facility's policy.

At interview with Staff #4 and Staff #5 on 4/9/15 at about 11:20 AM, they acknowledged the lack of consistent implementation of patients' plan of care for repositioning at two hours intervals.


Review of medical record for Patient #4 on 4/9/15 noted the patient was admitted on 4/1/15 from a nursing home with fever of unknown origin and lethargy. Nursing admission assessment revealed an unstageable sacral ulcer measuring 12 cm x 12 cm x 3 cm with 2 cm tunneling. The pressure ulcer had moderate foul drainage. The patient's past medical history is significant for diabetes mellitus, hypertension, chronic kidney disease, seizures, hyperlipidemia [elevated levels of any or all lipids (fat-soluble molecules) and /or lipoproteins (lipids transported in a protein capsule) in the blood], peripheral vascular disease, coronary artery disease, dementia, lung cancer, and dementia.

The facility's policy titled "Pressure Ulcer Prevention and Management" notes that nursing responsibility includes an assessment of patients on admission and referral to Dietitian for nutritional assessment.

There was no dietary consult located in the medical record for this patient who had been hospitalized for eight days.

At interview with Staff #6 on 4/9/15 at about 12:35 PM, she stated Patient #3 had not been referred for dietary consultation.