HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to initiate the grievance process regarding a patient that requested to leave against medical advice (AMA), as required by policy.

Findings include:

1. The Hospital's policy titled, "CORE: Discharge Against Medical Advice" (dated 6/2021), was reviewed on 9/7/0222, and required, "This policy establishes guidelines for discharge of the competent patient who wishes to leave against medical advice (AMA), and to insure proper documentation in the patients record... AMA is considered a grievance and shall be logged on the Complaint and Grievance Form as well as adherence to the expectations outlined in policy."

2. The Hospital's policy titled, "CORE: Responsibilities in Complaint and Grievance Reporting" (dated 6/2019). was reviewed on 9/7/2022, and required, "...Department Head/Management Obligation. Investigate>Document>Act>Respond. Conduct investigations into complaints assigned to by the DQM [Director of Quality Management]...Maintain all investigation documentation, including the Complaint and Grievance Form and interview notes in the file folder provided by the DQM..."

3. The clinical record for Pt #1 was reviewed on 9/6/022. Pt #1 was admitted on 7/4/2022 to the HAU (high acuity unit), with respiratory failure. A nursing note (dated 7/24/2022), included, "Patient was transferred to another hospital, departed at 2015 [8:15 PM] by 3 EMT's [emergency medical technician], 3 family members present, patient left on BIPAP [high pressure airway delivery system] and 2 drips ...patient stable at this time, no distress." The "Release from Responsibility from Discharge" (AMA form), dated 7/24/2022, was signed by Pt #1's daughter and witnessed by a nursing supervisor and another nurse.

4. The Hospital's Complaint/Grievance log, from 3/2022-8/31/2022, was reviewed and included one complaint from Pt #1's daughter on 7/13/2022, regarding repositioning and the Hospitalist's plan of care. The log lacked a grievance related to Pt #1 signing out AMA.

5. On 9/8/2022 at 10:05 AM, an interview was conducted with the Director of Quality Management (E #14). E #14 stated that on 7/24/2022, there was a missed STAT (immediately) hemodialysis order for Pt #1. E #14 stated that at that point, this was the "last straw" for the patient's family, and this is when they decided to send her out AMA. E #14 stated that although an event report was done regarding Pt #1 signing out AMA, there was not a grievance done.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #1) who left against medical advice (AMA), the Hospital failed to ensure the patient's right to be informed of his or her health status risks when refusing treatment and signing out AMA.

Findings include:

1. The Hospital's policy titled, "CORE: Discharge Against Medical Advice" dated 6/2021, was reviewed on 9/7/2022, and required, "This policy establishes guidelines for discharge of the competent patient who wishes to leave against medical advice (AMA), and to ensure proper documentation in the patient record ...Notify the patient's physician ...The patient's physician should speak with the patient to answer questions and to assist in the informed consent process."

2. The clinical record for Pt #1 was reviewed on 9/6/022. Pt #1 was admitted on 7/4/2022 to the HAU (high acuity unit), with respiratory failure. Pt #1 left the Hospital AMA (against medical advice) on 7/24/2022. A nursing note (dated 7/24/2022), included, "Patient was transferred to another hospital, departed at 2015 [8:15 PM] by 3 EMT's [emergency medical technician], 3 family members present, patient left on BIPAP [high pressure airway deliver] system and 2 drips ...patient stable at this time, no distress." The "Release from Responsibility from Discharge" (AMA form), dated 7/24/2022, was signed by Pt #1's daughter and witnessed by a nursing supervisor and another nurse. Pt #1's Discharge Summary, dated 7/26/2022 (2 days post discharge), documented by MD #5, included, "Patient was transferred to acute care hospital per family request." A review of the physician progress notes, lacked documentation of informing the patient of risks of discharge/AMA on the date of discharge.

3. On 9/7/2022 at 1:15 PM, an interview was conducted with the Clinical Educator (E #10). E #10 stated that a physician should be notified when a patient wants to sign out AMA and there should be documentation that supports the MD speaking with the patient and family discussing risks of leaving against medical advice.

4. On 9/8/0222 at 9:00 AM, an interview was conducted with the Nursing Supervisor (E #15). E #15 stated that Pt #1's family was requesting a transfer to another hospital because they didn't feel like the treatment was aggressive enough here at this hospital. E #15 stated that patient was stable enough for a short distance travel, but it is generally the physician's decision and assessment that determines that. E #15 stated that a doctor did not see Pt #1 at discharge. E #15 stated that they should document in the medical record a "change of condition" note.

A. Based on document review and interview, it was determined that for 1 of 3 (Pt.#1) clinical records reviewed for wound care management, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to complete the physician's order for wound care.

Findings include:

1. The Hospital's policy titled, "CORE: Clinical Guidelines for Pressure Injury" (dated 6/2022), was reviewed on 9/7/2022, and required, "This policy and procedures establish guidelines for the RN's role in preventing and treating pressure injuries based on Braden Risk score and subscales...The frequency of wound dressing change is dependent upon various clinical indicators. Examples include but are not limited to: a. Physician order. 8. Documentation: Within the electronic/paper medical record document: Execution of order..."

2. The clinical record for Pt #1 was reviewed on 9/6/022. Pt #1 was admitted on 7/4/2022 to the HAU (high acuity unit), with respiratory failure.
- Pt #1's admission nursing note, dated 7/5/2022, included, " ...arrived from [an acute care hospital] per stretcher-conscious...Pressure injury: bil [bilateral] lower leg ulcers ...present on admission ..."
- Pt #1's wound care orders included the following orders for treatment (dated 7/5/2022):
- Wound care: right lower leg, cleanse wound with (and pat dry): wound cleanser, Xeroform to open areas daily.
- Wound care: left lower leg, cleanse wound with (and pat dry): wound cleanser, Thera honey and alginate to open areas, daily.
- Wound care: L (left) chest, cleanse wound with (and pat dry); wound cleanser, paint with betadine, daily.
- Pt #1's Nurses Notes, from 7/5/2022-7/24/2022, indicated whether the wound care orders were executed from either the wound care team or the floor nurses. The wound care was not done on 7/13/2022 due to patient refusal. The clinical record lacked documentation of wound care treatment being executed as ordered on 7/14/2022 and 7/15/2022. There was no indication that the patient refused treatment on these dates.

3. On 9/7/2022 at 10:20 AM, an interview was conducted with the Wound Care Coordinator (E #12). E #12 stated that Pt #1 came into the facility with 3 wounds (2 mixed vascular lower extremity and one to the chest). E #12 stated that the wound care orders included Xerofoam, Thera Honey and Betadine paint. E #12 stated acknowledged that Pt #1's wound care orders on 7/14/2022 and 7/15/2022 were not carried out as ordered. E #12 stated that orders should be executed or documentation should reflect why the order was not carried out.


B. Based on document review and interview, it was determined that for 2 of 3 (Pt.#1, Pt #2) clinical records reviewed for wound care management, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to turn and reposition a patient every 2 hours, as required.

Findings include:

1. The Hospital's policy titled, "CORE: Clinical Guidelines for Pressure Injury" (dated 6/2022), was reviewed on 9/7/2022, and required, "This policy and procedures establish guidelines for the RN's role in preventing and treating pressure injuries based on Braden Risk score and subscales...Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum Q2 [every 2 hours] turns..."

2. The clinical record for Pt #1 was reviewed on 9/6/022. Pt #1 was admitted on 7/4/2022 to the HAU (high acuity unit), with respiratory failure. Pt #1's admission nursing note, dated 7/5/2022, included, " ...arrived from [an acute care hospital] per stretcher-conscious ...Pressure injury: bil [bilateral] lower leg ulcers ...present on admission ..." Pt #1's order for repositioning (dated 7/4/2022), included, "Reposition, as tolerated, q2h [every 2 hours]." Pt #1's repositioning notes, from 7/4/2022-7/24/2022, were reviewed and lacked the required repositioning every 2 hours on:
- 7/5/2022: from 06:00 AM, supine (back) to 9:00 AM, right side (3 hours)
- 7/5/2022: from 11:33 PM, supine, to 7/6/2022 at 2:48 AM, right side (3 hours 15 minutes)
- 7/6/2022: from 6:00 PM, supine, to 8:52 PM, right side (2 hours 52 minutes)
- 7/7/2022: in supine position from 2:00 PM to 6:00 PM (4 hours)
- 7/8/2022: from 4:00 PM, left side, to 7:32 PM, supine (3 hours 32 minutes)
- 7/10/2022: from 4:00 AM, left side, to 7:20 AM, supine (3 hours 20 minutes)
- 7/11/2022: from 3:51 AM, left side, to 6:27 AM, supine (2 hours and 36 minutes)
- 7/12/2022: from 4:37 AM, supine, to 8:00 AM, left side (3 hours and 23 minutes)
- 7/14/2022: from 6:00 PM, supine, to 10:00 PM, left side (4 hours)
- 7/15/2022: from 4:00 PM, right side, to 8:00 PM, right side (4 hours)
- 7/17/2022: from 4:00 AM, left side, to 8:14 AM, supine (4 hours and 14 minutes)
- 7/19/2022: from 10:01 AM, left side, to 1:47 PM, supine (3 hours and 46 minutes)
- 7/19/2022: from 4:00 PM, left side, to 6:55 PM, left side (2 hours and 55 minutes)
- 7/23/2022: from 3:49 AM, right side, to 8:00 AM, left side (4 hours and 11 minutes).

3. The clinical record of Pt. #2 was reviewed on 9/6/2022. Pt. #2 was admitted on 4/26/2022 with a diagnosis of respiratory failure. Pt. #2's admission nursing assessment, dated 4/26/2022, indicated that Pt. #11 was completely immobile and bed bound, and had a Braden Score (risk of developing a pressure ulcer) of 13 (moderate risk). A physician's order, dated 4/26/2022, included, "Turn and Reposition ...q2h (every 2 hours)." Pt. #2's repositioning notes from 5/15/2022-5/23/2022 were reviewed and indicated the following:
- 5/16/2022: Patient was documented on left side from 4:00 AM to 6:40 AM (2 hours and 40 minutes) and on right side from 6:18 PM to 10:00 PM (3 hours and 42 minutes).
- 5/17/2022: Patient was documented on right side from 7:29 AM to 10:12 AM (2 hours and 43 minutes).
- 5/20/2022: Patient was documented in supine (back lying) position from 5:42 AM to 10:00 AM (4 hours and 18 minutes) and on left side from 5:01 PM to 8:00 PM (2 hours and 59 minutes).
- 5/21/2022: Patient was documented on left side from 4:00 PM to 8:00 PM (4 hours) and on right side from 8:00 PM to 11:57 PM (3 hours and 57 minutes).
- 5/22/2022: Patient was documented on left side from 2:09 AM to 5:51 AM (3 hours and 42 minutes).
- 5/23/2022: Patient was documented on right side from 7:55 AM to 12:45 PM (4 hours and 50 minutes); in supine position from 12:45 PM to 5:07 PM (4 hours and 22 minutes); and on right side from 6:50 PM to 9:45 PM (2 hours and 55 minutes).

4. On 9/7/2022 at 10:20 AM, an interview was conducted with the Wound Care Coordinator (E #12). E #12 stated that Pt #1 came into the facility with 3 wounds (2 mixed vascular lower extremity and one to the chest). . E #12 stated that Pt #1 was ordered heel protectors, offloading, and repositioning. E #12 stated that patients are required to be turned at least every 2 hours, as tolerated. E #12 stated that if they are not able to be turned then the staff should document the reason why they were not turned.