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Based on record review and interview, the hospital failed to provide written notice of the grievance decision. The deficient practice is evidenced by failure to send a letter describing the steps taken on behalf of the patient, the results of the grievance process, and the completion date to 1 (Patient #3) of 1 reviewed grievances over 30 days old.

Findings:

Review of the grievance investigation for Patient #3 revealed the grievance process was initiated on 11/2/2023. The "file state" listed on the report was "In-progress." The report documented the interviews with the patient and hospital staff and steps taken after the grievance was initiated, but failed to reveal a letter was sent at the completion of the investigation.

In interview on 12/04/2023 between 1:30 p.m. and 1:40 p.m., S1VPN verified the investigation was never properly closed and a letter was not sent to Patient #3 to inform her of the investigation results.

Based on record review and interview, the hospital failed to ensure proper documentation of informed consent. The deficient practice is evidenced by failure to document risks, benefits, and alternative treatments were discussed with the consenting adult in 1 (Patient #1) of 1 reviewed patient record where consent was obtained over the telephone.

Findings:

Review of the policy "Informed Consent Policy No. 228," reviewed 07/21, revealed in part, " In addition, The provider shall be responsible for the completion of the informed consent form with the following information: . . . g. Material risks, benefits, side effects and reasonable alternatives of the treatment."

Review of the medical record for Patient #1 revealed a procedure note on 10/03/2023 at 8:41 p.m. A Peripherally Inserted Central Catheter (PICC) was inserted. The procedure note and the progress note for 10/03/2023 both document that consent was obtained from the mother, but the record did not include documentation the risks, benefits, side effects and reasonable alternatives were discussed.

In interview on 12/05/2023 at 9:45 a.m., S1VPN verified the physician did not follow hospital policy. S1VPN verified the physician should have documented that the risks, benefits, and alternative treatments were discussed and the mother had all questions answered before giving consent.

Based on record review and interview, the hospital failed to ensure nursing staff adhered to infection control policies. The deficient practice is evidenced by failure to initiate isolation precautions immediately after notification of an epidemiologically significant pathogen in 2 (#2, #3) of 3 (#1, #2, #3) reviewed medical records of patients with infectious pathogens.

Findings:

Review of the policy, "Standard and Isolation Precautions," Infection Prevention Policy No. 4.2, reviewed 02/2023, revealed in part, "Responsibility . . . B. Attending Physician/ Registered Nurse- 1. Initiate isolation precautions based on known or suspected diseases as detailed in Appendix C and Appendix D." Review of Appendix C titled, "Recommendations for Isolation Precautions in Hospitals" includes instructions for isolation for multidrug resistant organisms and Influenza.

Review of the policy, "Critical Results of Tests and Diagnostic Procedures," Administrative Policy No. 198, reviewed/revised 10/2021, revealed in part, "Physician Critical Alert Values- The following results are to be CALLED AND READ BACK by the patient's nurse if INP and office if OP. . . . MICROBIOLOGY . . . MRSA on inpatient . . . INFECTIOUS DISEASE POSITIVES- Respiratory Panel. . Flu A and B . . ."

Patient #2
Review of the medical record for Patient #2 revealed admission on 12/02/2023 for active labor at 39 0/7 weeks gestational age. The patient was noted to be febrile on presentation and fetal tachycardia was documented. On 12/02/2023 at 8:40 p.m., laboratory staff documented the positive result for Influenza A was reported to the registered nurse caring for Patient #2. On 12/02/2023 at 7:52 p.m., an infection prevention consult was ordered.

Further review of the medical record revealed droplet precautions were first documented as implemented on 12/03/2023 at 2:00 p.m. and the infection prevention consult was performed on 12/04/2023 at 6:52 a.m.

In interview on 12/05/2023 at 10:10 a.m., S1VPN and S2VPQ verified the nursing staff should have immediately implemented and documented the use of isolation/droplet precautions. S1VPN verified the nursing staff did not document the use of isolation/droplet precautions in the first 17 hours after the positive result.

Patient #3
Review of the medical record for Patient #3 revealed admission on 10/20/2022 for active labor with spontaneous rupture of membranes at 41 1/7 weeks gestational age. The physician noted fetal tachycardia and late fetal decelerations remote from delivery. A cesarean section was performed and swab samples from the placenta were collected for cultures. A presumptive positive result for methicillin resistant staphylococcus aureus (MRSA) was called to the registered nurse caring for Patient #3 on 10/22/2022 at 11:18 a.m. and a confirmation of the positive result was called to the registered nurse caring for Patient #3 on 10/23/2022 at 8:38 a.m. The report also documented, "MRSA- Inpatient isolation required. Notify Infection Prevention if inpatient."

Review of the orders for Patient #3 revealed the post-partum order set contained reflex orders for cultures positive for MRSA which included Bactroban 2% 1 gram ointment and contact isolation.

Further review of the medical record for Patient #3 failed to reveal documentation the patient was placed on isolation or contact precautions during the admission. An infection prevention consult was not ordered and the patient was never given the Bactroban ointment.

In interview on 12/04/2023 between 2:30 p.m. and 3:00 p.m., S1VPN verified Patient #3 should have been put in isolation and the nursing should have immediately started documentation of the use of the precautions. S1VPN verified the infection control consult was not ordered and the standing orders for the isolation and Bactroban were never initiated.