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Based on staff interview, medical record review, and review of policies and procedures, the facility failed to ensure prompt resolution for 1 of 1 sample patient whose representative voiced a grievance regarding the care the patient received. The findings were:

According to the medical record for patient #8, the patient had knee surgery on 3/6/13 and remained in the hospital until 3/13/13. Random reviews of the nursing and physician progress notes revealed the patient's representative was concerned about his/her care. During an interview on 6/7/13 at 12:20 PM the risk manager revealed she first became aware of patient #8's representative's concerns during a conversation with the patient representative about one or two days after the patient was discharged. The risk manager stated she and two additional staff had a meeting with the patient representative, the concerns were discussed, but nothing was documented. In an interview on 6/7/13 at 12:30 PM, the nurse manager stated the date of the meeting was 3/22/13 and she was one of the staff that attended the meeting. She stated she did not "feel" the patient representative's concerns were resolved at the meeting.

Review of the Patient Grievance Policy, effective date 10/2010, showed appropriate personnel must review, investigate, and resolve each grievance within a reasonable time frame. This review also showed "once the investigation is complete, the investigator will provide the patient or their representative with a written notice of any findings, steps that were taken during the investigation, date of completion, and contact information for the Department of Health and the name of the contact person for any additional questions or concerns."

During the interview with the risk manager on 6/7/13 at 12:20 PM, she verified that none of the above procedures had not beeen followed to address the patient representative's concerns. At that time she acknowledged the policy and procedures should have been followed.

Based on staff interview and medical record review, the facility failed to develop a system for effectively identifying areas of nursing care that needed improvement. The facility's review of nursing care failed to identify that staff did not consistently document the amount of medication received by 1 of 2 sample patients (#8) who received patient controlled analgesia (PCA). In addition, the facility failed to complete a review of the nursing care for 1 of 1 sample patient (#6) whose nurse reported concerns about the patient's care. The findings were:

1. Review of the medical record for patient #8 revealed the patient had knee surgery on 3/6/13 and was admitted to the hospital. Further review showed on the day of the surgery a morphine (a narcotic used for pain) PCA was started. In an interview on 6/6/13 at 10:55 AM, the quality nurse stated the physician ordered the following for morphine PCA administration:1 milligram (mg) every hour, 1 mg every 8 minutes per patient self administration and an additional 2.5 mg bolus that could be administered by the nurses every 15 minutes. The quality nurse further stated the physician's 3/7/13 order timed at 6:40 AM instructed staff to "wean from PCA". Review of the medical record showed the the PCA settings were decreased later that day. Review of documentation by RN #1 showed she discontinued the morphine PCA at 9:14 PM on 3/7/13, and the rate at that time was 1.5 mg every hour with l mg every 15 minutes as needed. According to the 3/7/13 medication administration record the patient received scheduled doses of oxycodone (a narcotic analgesic used to treat pain) 10 mg at 10:10 AM and 9:32 PM. This review also showed 10 mg of as needed oxycodone was administered at 2 PM and 7:28 PM. Review of RN # 1's documentation showed the rapid response team was called on 3/8/13 at 2:13 AM due to the patient's low oxygen saturation rate and confusion. Review of the 3/8/13 physician's progress note showed the rapid response team administered narcan .2 mg (a narcotic antagonist used to counteract the effects of narcotics) and the patient recovered from this "hypoxic" episode. This review also revealed the patient periodically removed his/her oxygen and it was questionable how much this contributed to the hypoxic episode. The following concerns were identified:
a. Review of the medical record showed the amount of morphine the patient recieved from the PCA had not been recorded. RN #1 who was responsible for the patient's care on 3/7/13 was interviewed on 6/8/13 at 6:15 PM. During the interview she confirmed she did not document the amount.
b. In an interview on 6/7/13 at 1:30 PM, the pharmacist stated he remembered the nursing staff asked him about the potential effects of receiving a total of 40 mg of oxycodone on 6/7/13, but he did not remember a discussion regarding how morphine and oxycodone cumulatively could potentially affect the patient. The pharmacist also stated neither the PCA machine; nor the pharmacy department had the capability of tracking the amount of morphine that the patient received if the nurse did not document the amount infused and, if applicable wasted, each time a new container of the medication was put in the PCA.
c. In an interview on 6/7/13 at 2 PM the quality manager and quality nurse stated the facility did not have a system for documenting the amount of medication that was received from the PCA, the amount the patient successfully self administered, the unsuccessful attempts to self administer, and bolus amounts administered by the nurses.
d. Interview with quality manager on 6/7/13 at 2 PM revealed this incident had been reviewed by the risk manager, but the review failed to identify problems with the facility's system for monitoring and documenting PCA medication infusion.

2. Review of the medical record for patient #6 revealed the patient was admitted to the hospital on 2/1/13 and had cardiac surgery for coronary artery disease. Further review of the medical record and interview on 6/8/13 at 6 PM with RN #2 who provided care for the patient revealed the following sequence of events. On 2/14/13 the patient had six episodes of diarrhea between 2 PM and 9 PM. At that time s/he was receiving antibiotic therapy and had a peripherally inserted central catheter (PICC) for intravenous infusion, and an indwelling urinary catheter. On 2/15/13, s/he continued to have episodes of diarrhea in addition to episodes of vomiting. At 3 PM that day, the patient's blood pressure was 98/51, pulse was 101 and respirations were 20. At 7 PM the patient's blood pressure was 92/59 and the documented pain assessment said the "patient denies pain". Four hours later, at 1 AM, the patient's blood pressure was 86/38. At 1:30 AM, the patient's blood pressure was 86/56. At that time RN #2 telephoned physician #1 and reported the low blood pressures, the ongoing vomiting and diarrhea, and the decreased urinary output. Physician #1 ordered 500 milliliters (ml) of intravenous normal saline to infuse at 100 ml an hour. On 2/16/13, an hour and a half later, the recorded blood pressures were 76/47 at 2 AM, 71/43 at 2:15 AM, 74/45 at 2:30 AM, and 76/53 at 2:45 AM.

At 3:18 AM, RN #2 telephoned physician #1 again and reported the continued low blood pressures. The RN also told the physician that the patient complained about not feeling well. The physician ordered an increase in the normal saline fluid rate to 250 ml an hour for one hour then resume the previous infusion rate of 100 ml an hour. The RN followed the physician's orders, but the change in infusion rate had little impact on the low blood pressures. At 5 AM, the patient's blood pressure was 67/59, pulse was 105 and oxygen saturation rate was 96% with continuos nasal cannula oxygen. At 5:15 AM, the patient's blood pressure was 85/52, pulse was 105 and oxygen saturation rate was 95% with continuous nasal cannula oxygen. At 5:30 AM, the patient's blood pressure was 74/52 and pulse was 103. At 6 AM, the patient was lethargic and pale, his/her blood pressure was 79/53, and the small amount of urine output was concentrated and bloody. At that time the rapid response team and the patient's family were called. By 7 AM, the patient had been moved to the intensive care unit and later received endotracheal intubation and cardiopulmonary resuscitation. According to the 2/16/13 code blue record flow sheet, the patient diagnosis included sepsis and post-operative coronary artery bypass surgery. The following concerns were identified regarding this patient's care.
a. In an interview on 6/8/13 at 6 PM RN #2 stated one of her concerns was that the patient's condition began to decline on 2/14/13, but this was not addressed more aggressively until the patient was in a pre-arrest state on 2/16/13 at 6 AM. The RN stated it was unclear what the physician's expectations were, and she had concerns about poor communication between the disciplines involved in this patient's care. She further stated as an advocate for the patient she reported her concerns to the charge nurse with the expectation that administrative nursing staff would follow up, but this did not occur.
Information regarding assessments and medication administration was requested by the surveyor.
b. Based on the information provided by the facility, a pain assessment was completed at 7 PM on 2/15/13, but there was no evidence an additional pain assessment was completed thereafter.
c. Based on the information provided by the facility there was no evidence the patient received medication for vomiting or diarrhea after 2/15/13 at 9 AM; or why it would have been contraindicated after that time.
d. Review of the medical record revealed the facility did not developed an interdisciplinary care plan for this patient. In an interview on 6/6/13 at 3:05 PM the quality nurse confirmed staff had not utilized the care planning process to establish a coordinated interdisciplinary approach to this patient's care.
e. During an interview on 6/7/13 at 1:45 PM, the quality manager stated the nursing staff had not reviewed the medical and nursing care that had been provided for patient #6 to identify measures the facility needed to implement to make improvements in the areas of documentation, assessments, and communication.