HospitalInspections.org

Based on record review (grievance log, medical records, policies/procedures) and interviews, the hospital failed to ensure patients' rights were protected in relation to the grievance process for 1 of 6 sampled patients (Patient #3). This was evidenced by the hospital's failure to provide the patient and/or patient representative with a written notice of its decision that included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and/or the date of completion.
Findings:
Review of Comply Track (Grievance Database) grievance log revealed a grievance was filed by Patient #3's son and POA (Power of Attorney) on 12/10/13.
Review of the Policy and Procedures entitled "Patient and Family Complaint/Grievance Process" presented by S2CNO (Chief Nursing Officer) as the current policy revealed, under the section, "Grievance Process," stated, in part: If resolved, the Compliance Officer shall confer with the Patient Concern Committee and coordinate the response letter to the patient. The written response to notify the patient of the hospital's decision will contain the following: (1) Name of the hospital contact person, (2) The steps taken on the patient's behalf to investigate the grievance, (3) The results of the investigation, and (4) The date of completion.
Patient #3:
Medical record review revealed Patient #3 was a 79-year-old female admitted to the hospital on 11/18/13 with an admitting diagnosis of elevated liver enzymes. Other diagnoses included Steven-Johnson Syndrome, Sepsis, Urinary Tract Infection, Atrial Fibrillation, Hypertension, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Cerebral Vascular Accident, Seizures, Hypothyroidism, and Dementia.
Review of Patient #3's medical record revealed Patient #3's son has Power of Attorney, and is the only child of Patient #3.
In a telephone interview on 12/30/13 at 2:07 p.m., Patient #3's son stated he is the only child of Patient #3 and has Power of Attorney for Patient #3.
Review of the Comply Track (Grievance Database) documented information revealed that S2CNO was assigned to investigate the grievance for Patient #3.
Review of the response letter mailed to Patient #3's son revealed the letter was dated 12/16/13. Review of the body of the response letter mailed to Patient #3's son revealed (in total): "This letter is a written follow-up to our recent phone conversation regarding your mother, (states the consumer's name here) hospital stay from 11/18/13 to 12/09/13. You indicated that you were not informed by our staff of your mother's return to the Nursing Home. Our policy is to notify family when a patient returns to the nursing home and appropriate action has been taken with involved staff members to assure that families are notified in a timely manner." Further review of the response letter revealed the letter was signed by S2CNO.
In an interview on 01/03/14 at 1:00 p.m., S2CNO confirmed she had composed the response letter regarding the grievance for Patient #3. S2CNO indicated the "(2) steps taken on the patient's behalf to investigate the grievance was documented in the response letter by the statement 'appropriate action has been taken with involved staff members to assure that families are notified in a timely manner;' (3) the results of the investigation was documented in the response letter by the statement 'our policy is to notify family when a patient returns to the nursing home;' and (4) The date of completion as '12/16/13' (when the response letter was mailed to Patient #3's son)." S2CNO agreed the body of the response letter did not explicitly state all the steps taken to investigate the grievance, the results of the investigation, and the date the investigation was completed. S2CNO confirmed she did not send the letter via certified mail, and she was not sure if Patient #3's son had received the letter, but the letter had not been returned to the hospital as undeliverable. S2CNO also indicated the address used to mail the letter was the address on the face sheet listed under the "Patient Address" section. S2CNO further indicated she had received no further communication from Patient #3's son since the response letter was mailed.
In an interview on 01/03/14 at 1:30 p.m., S8Compliance (Compliance Officer) indicated she did not know if Patient #3's son received the response letter, but the response letter had not been returned to the hospital as being undeliverable. S8Compliance further stated she had not received any further communication from Patient #3's son since the response letter was mailed.

Based on record review (medical records, policies and procedures) and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for 1 of 6 sampled patients (Patient #3). This was evidenced by the hospital's failure to ensure that the registered nurse assessed and evaluated Patient #3's meal and supplemental intake on a consistent basis.

Findings:

Patient #3

Review of Patient #3's medical record revealed the patient was a 79-year-old female admitted to the hospital on 11/18/13 with an admitting diagnosis of elevated liver enzymes. Other diagnoses included Steven-Johnson Syndrome, Sepsis, Urinary Tract Infection, Atrial Fibrillation, Hypertension, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Cerebral Vascular Accident, Seizures, Hypothyroidism, and Dementia.

Review of the physician's orders dated 12/05/13 at 8:00 a.m. revealed an order to "consult dietary to address electrolyte and nutrition concerns."

Review of the Patient #3's medical record revealed that Patient #3's admission weight was documented as 54.7 kg and discharge weight was documented as 55.9 kg. Review of the "Patient Flowsheet" revealed Patient #3's "Meal/Supplemental Intake" was not consistently documented in Patient #3's medical record. Further review of the Patient Flowsheet revealed the following Meal/Supplemental Intake sections were not completed by the nurse in the medical record during the dates of 12/02/13 through 12/09/13:
12/02/13: No documentation of meal/supplemental intake documented for lunch, or dinner
12/03/13: No documentation of meal/supplemental intake documented for dinner
12/04/13: No documentation of meal/supplemental intake documented for breakfast, lunch, or dinner
12/05/13: No documentation of meal/supplemental intake documented for breakfast, lunch, or dinner
12/06/13: No documentation of meal/supplemental intake documented for breakfast, lunch or dinner.
12/07/13: No documentation of meal/supplemental intake documented for lunch, or dinner.
12/08/13: No documentation of meal/supplemental intake documented for breakfast, lunch, or dinner.
12/09/13: No documentation of meal/supplemental intake documented for breakfast, lunch, or dinner.
Review of the Policies and Procedures entitled "Documentation of Nursing Care" provided as the current policy and procedure in use by S2CNO revealed, in part, the purpose of the policy and procedure was to standardize and integrate the assessment/reassessment and documentation process into an interdisciplinary plan of care through systematic collection, review, and processing of patient related data; to establish guidelines to aid in standardizing the patient care process. Specific care needs of the individual patient may warrant deviation from the guidelines; to incorporate focus charting as the method of nursing documentation at the hospital. Further review of the policy under the section entitled "Responsibility/ Authority" and subsection "24-Hour Nursing Documentation" revealed, in part, the data documented during the patient's hospital stay will include: vital signs/intake and output, nursing procedures, and any other pertinent information.

In a telephone interview on 01/08/14 at 2:30 p.m., S2CNO indicated the nurses are responsible for documenting meal/supplemental intake information in the medical record.
In a telephone interview on 01/09/14 at 9:45 a.m., S2CNO verified she had submitted all documentation in Patient #3's medical record regarding the documentation of meal/supplemental intake for Patient #3. S2CNO also confirmed the nurses failed to consistently document in Patient #3's medical record Patient #3's meal/supplemental intake information.

Based on record review (medical records, policies and procedures), and interviews, the hospital failed to ensure a discharge plan was implemented in accordance with discharge planning policies and procedures for 1 of 6 sampled patients (Patient #3). This was evidenced by failure of the nursing staff to document on the medical record notification of the family member of Patient #3's discharge from the hospital.
Findings:
Review of the Policies and Procedures entitled "Discharge Process" presented by S2CNO (Chief Nursing Officer) as the current policy and procedure in place revealed, in part, under Section III, Day of Discharge:
b. The discharge procedure is explained to them by the physician and/or a member of the nursing staff. The nurse caring for the patient with assistance from the healthcare team, is responsible for completing the Patient Discharge Instruction Sheet. This is done at the time of discharge making sure all areas are complete and all questions answered (including medication reconciliation information).
d. Contact transportation ambulance service and/or significant other accompanying the patient at discharge in advance when order is received. Ask the patient whom to notify and instruct regarding his/her discharge if necessary.
e. Patient Discharge Instruction Sheet can be found in Form Fast (under Discharge-Transfer Menu/Discharge to/Home). Instructions are to be explained to the patient verbally and verified by the patient/significant other that instructions are understood. A written copy of these instructions is signed by the patient or significant other, indicating that instructions have been given and are understood. In addition, the staff member giving instructions also signs the form. A copy of the instructions is given to the patient and the original is kept with the patient's record.
h. Verifying patient/family understanding at the time of discharge with discharge instructions and medication reconciliation.
Patient #3:
Medical record review revealed Patient #3 was a 79-year-old female admitted to the hospital on 11/18/13 with an admitting diagnosis of elevated liver enzymes. Other diagnoses included Steven-Johnson Syndrome, Sepsis, Urinary Tract Infection, Atrial Fibrillation, Hypertension, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Cerebral Vascular Accident, Seizures, Hypothyroidism, and Dementia.
Review of Patient #3's medical record revealed Patient #3's son is the patient's designated POA (Power of Attorney).
In a telephone interview on 12/30/13 at 2:07 p.m., Patient #3's son stated he is the only child of Patient #3 and has Power of Attorney for Patient #3.
In an interview on 01/02/14 at 9:15 a.m., S2CNO (Chief Nursing Officer) indicated the nurse discharging the patient was responsible for filling out the "Transfer Summary and Orders-Return to Nursing Home" form and is responsible for contacting the family regarding the discharge status.
Review of Patient #3's medical record revealed discharge orders were written on 12/09/13 at 2:23 p.m. by S6MD. Further review of the discharge orders revealed S5RN (Registered Nurse) signed off on the discharge orders on 12/09/13 at 4:11 p.m. and S5RN was the nurse who discharged Patient #3.
Review of the Nurse's Notes dated 12/09/13 revealed there was no documentation by S5RN that Patient #3's son had been notified of Patient #3's discharge from the hospital on 12/09/13. Further review of the Nurse's Narrative Notes dated 12/09/13 at 8:22 p.m. revealed S5RN documented that patient was being transported to Facility A via ambulance, and report was given to S11LPN (Licensed Practical Nurse) at Facility A.
Review of the form entitled "Transfer Summary and Orders-Return to Nursing Home" revealed a discrepancy in regards to Patient #3's date of discharge. The "Requested Date" was documented as 12/09/13 which was the actual date of Patient #3's discharge. Under the heading entitled "Transfer Information" the transfer date documented was 11/27/13, the transfer time was 10:41 a.m., and the person accepting for receiving facility was a licensed practical nurse at Facility A. Under the subheading "Family/SO (significant other) notified of transfer," the documented answer was "yes" with no name documented identifying the person notified.
In a telephone interview on 01/03/14 at 11:42 a.m., S5RN indicated that she was the nurse who discharged Patient #3 from the hospital to Facility A on 12/09/13, and was responsible for completing the discharge paperwork and forwarding the discharge paperwork to Facility A. S5RN indicated she was informed by S4CM (Case Manager) that Patient #3 was accepted back to Facility A, but may not have documented that information in the medical record. S5RN further indicated she was responsible for notifying Patient #3's son of discharge and reported that she did not notify Patient #3's son of Patient #3's discharge on 12/09/13.
S5RN indicated that she could not explain the discrepancy on the form entitled "Transfer Summary and Orders-Return to Nursing Home" relating to the transfer date being documented as 11/27/13; the transfer time being documented as 10:41 a.m.; a nurse, other than S11LPN, as having received report on Patient #3 at Facility A; and the section "Family/SO notified of transfer" had a documented answer of "yes" with no name of the family member contacted documented. S5RN confirmed it was possible that the electronic form may have been initiated on 11/27/13 because Patient #3 was originally scheduled to be discharged from the hospital on that date; however, the discharge was canceled on 11/27/13 due to a change in Patient #3's health status.
In an interview on 01/03/14 at 9:38 a.m., S9Quality Director (Director of Quality) indicated that the "Requested Date" of 12/09/13 printed at the top of the "Transfer Summary and Orders-Return to Nursing Home" form for Patient #3 was the day the nurse printed out the form. S9Quality Director further indicated that she could not explain the discrepancy in the Requested Date of 12/09/13 (date of Patient #3's discharge) at the top of the form and the transfer date of 11/27/13 documented under the "Transfer Information" section of the form. S9Quality Director indicated that Patient #3's actual discharge date was 12/09/13.
In an interview on 01/03/14 at 9:45 a.m., S2CNO indicated she could not explain the discrepancy in the Requested Date of 12/09/13 (date of Patient #3's discharge) at the top of the form and the transfer date of 11/27/13 documented under the "Transfer Information" section of the form. S2CNO indicated she had interviewed S5RN and was informed by S5RN that she had not contacted Patient #3's son of Patient #3's discharge on 12/09/13. S2DON further indicated she could not explain the discrepancy in documentation under the section "Family/SO (significant other) notified of transfer was documented as "yes" with no name documented identifying the person notified. S2CNO indicated that Patient #3's actual discharge date was 12/09/13.
In an interview on 01/03/14 at 11:17 a.m., S3CM indicated that she had only spoken to Patient #3's son once, and she did not speak to him on the day Patient #3 was discharged from the hospital back to Facility A.
In an interview on 01/03/14 at 11:36 a.m., S7SSW (Social Service Worker) indicated she was consulted to see Patient #3 on 11/19/13, and this was the only involvement with Patient #3 during this hospital stay. S7SSW further indicated she did not contact Patient #3's son regarding discharge from the hospital to Facility A.
Review of the Nurse's Notes dated 12/09/13 at 6:21 p.m. from Facility A revealed Patient #3's son indicated he was not notified that Patient #3 was discharged from the hospital on 12/09/13. Further review of the Nurse's Notes dated 12/10/13 at 10:25 a.m. revealed Patient #3's son contacted Facility A and stated that Patient #3 should still be in the hospital, and that the hospital sent Patient #3 back to Facility A without notifying him (Patient #3's son). Further review of the Nurse's Notes revealed Patient #3's physician at Facility A notified the hospital of Patient #3's son's complaint.
In an interview on 01/03/14 at 10:20 a.m., S11LPN (Facility A) indicated that she was informed by the nurse from the previous shift that Resident #3 was being discharged from the hospital and was returning to Facility A on 12/09/13. She further indicated that when she contacted Patient #3's son regarding Patient #3, he (Patient #3's son) was very upset, and stated he had not been notified by the hospital that Resident #3 had been discharged from the hospital and transferred back to Facility A.