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Based on interviews and record reviews the hospital failed to ensure that acceptable infection control protocols, on the identification, reporting, investigating and controlling of infections and communicable disease of patients and personnel, were adhered to as evidenced by the infection control surveillance program failing to place 1 of 1 patient (Patient #5) suspected of a surgical site wound infection on isolation precautions prior to lab report results being reported.

Findings:
A review of the the hospital's Isolation Guidelines- General Procedures, as provided by S4RN/ICN as the most current, revealed in part: Patients with draining wounds will be isolated until such times as cultures make it clear that pathogenic bacteria are not present. When such patients are not isolated by order of their physician, the charge nurse will notify the infection control nurse who will report this to the Chairman of the Infectious Control Committee.

A review of Patient #5's medical record revealed in part: patient was a 78 year old female, status post exploratory laporatomy surgical procedure admitted to the hospital on 6/26/15 under the care of S5Medical Director for wound care for an abdominal wound dehiscence. A review of the nurse's, "Wound Documentation" sheet dated 7/10/15 revealed in part: Abdominal wound care as ordered, serosanguineous purulent drainage with peripheral tissue edema noted. A review of the Physician Order sheet revealed an order dated 7/10/15, co-signed by S5Medical Director, for a wound C&S (culture and sensitivity) of the abdominal wound. There was no documented evidence of a Physician Order for any isolation precautions. The culture was taken and sent to the lab on 7/10/15.

In an interview on 7/17/15 at 2:10 p.m. with S10RN (Registered Nurse), she indicated that she was probably the charge nurse on 7/10/15 when Patient #5's cultures were obtained and sent to the lab. S10RN was asked if Patient #5 had been placed on any isolation precautions until her lab culture results were reported. S10RN indicated that S5Medical Director did not order any isolation precautions for Patient #5. S10RN further indicated that she did not think that nurses could place patients on isolation precautions without a physician order. S10RN indicated that she had been employed for a few months and had received infection control in-services upon hire.

In an interview on 7/17/15 at 2:15 p.m. with S4RN/ICN (Infection Control Nurse) she indicated that she was the designated Infection Control Officer for the hospital. S4RN/ICN was asked if nurses could place patients on isolation precautions without a physician order. S4RN/ICN indicated that nurses could initiate isolation precautions without a physician order. S4RN/ICN was asked about Patient #5's C&S.. S4RN/ICN indicated that she was not aware the Patient #5 had had a C&S ordered. S4RN/ICN indicated that she performed chart audits randomly and had not performed any chart audits in over a week. S4RN/ICN was asked if nurses were supposed to contact the Infection Control Nurse when C&S were ordered by physicians and before the lab results were obtained from the lab. S4RN/ICN indicated that staff are required to notify the Infection Control Nurse of any C&S cultures. S4RN/ICN further indicated that all staff are in-serviced on infection control protocols upon hire and annually. S4RN/ICN indicated that she did not think that patients had to be on any isolation precautions if the drainage was minimal and covered, even if they suspected a wound infection. S4RN/ICN indicated that she had been the Infection Control at the hospital for about one year and attended several infection control in-services/programs.

Based on record review and interviews, the hospital failed to ensure patient's rights for changes in care and treatment were enacted for a patient whose capability to make decisions about care and treatment was impaired by failing to follow the hospital's policy and procedure for complaints and grievances for 1 (#3) of 5 records reviewed for patient's rights.
Findings:
Review of the hospital's policy entitled, "Grievance Policy and Procedure" dated 10/24/13 revealed, in part: "All patients or attending family member shall receive a Patient's Bill of Rights upon admission, and will be informed through this Bill of Rights of their right to complain concerning the quality of care. Presentation of a complaint does not compromise a patient's future access to care. The Hospital's Grievance Committee consists of the Hospital Administrator and Quality Assurance Director. The Board of Commissioners has delegated the responsibility of reviewing and resolving grievances to the grievance committee. Any person who believes she or he has been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for the facility to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance. Procedure: 1. The patient has a right to complain regarding the quality of care and will receive response from the organization that substantially addresses the complaint. Complaints should be presented to the Quality Assurance Director, (address and telephone number provided). If the patient chooses not to address his/her complaint to this facility, he/she has the right to contact: Department of Health and Hospitals (Address and toll free number provided). 2. A complaint may be verbal or in writing and should include the name and address of the person filing it ...All grievances whether verbal or written shall be documented on a grievance form and logged on the grievance log. 3. Upon receiving a verbal complaint, a complaint report form (see attached form) will be completed by the employee receiving the complaint. Administrator or DON (Director of Nursing) will be notified no later than the day following the receipt of a complaint/grievance. 4. Complaints will be referred to the Quality Assurance Director and a 'Lead Investigator' will be assigned within 24 hours of receipt of grievance. 5. The Lead Investigator shall ensure a complete investigation is conducted and prepare a report for the Quality Assurance Director. (The lead investigator may designate other staff members to participate in the investigation.) 6. The Grievance Committee will develop a corrective plan of action to resolve current grievance and to prevent future grievances. 7. The hospital will make every effort to resolve Grievances within 7 days of receipt of the grievance. If the grievance will not be resolved or the investigation is not complete within 7 days of receipt of the grievance, the hospital will notify the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow up with a written response within 30 days of the grievance being filed. 8. Upon resolution of the grievance, the Quality Assurance Director will provide the following written communication to the complainant: a. Description of complaint; b. Steps taken to resolve complaint; c. Date of completion/resolution; d. name of hospital contact person."
A review of the medical record for Patient #3 revealed she was a 72-year-old female admitted to the hospital on 05/20/15 from an acute care hospital. Diagnoses included: Infected coccyx decubitus, Stage IV, with palpable bone; Sepsis (Resolved) History of Cerebral Vascular Accident (CVA) with Craniotomy (2014); Chronic Tracheostomy; Chronic PEG (percutaneous endoscopic gastrostomy) tube; Persistent Vegetative State; Obesity; Mild Contractures of Knees. The patient was a full code status. The patient was discharged to home on 06/24/15 to the care of the Responsible Party with home health services as indicated in the discharge planning assessments and documentation performed by the disciplines.
Further review revealed Patient #3 was being cared for at home by her brother (Responsible Party) prior to admission to the hospital. The Responsible Party stated to the hospital staff he had Power of Attorney for Patient #3. There was no documentation in Patient #3's medical record which indicated the listed Responsible Party, or any other family member, had Power of Attorney for Patient #3 though the hospital had attempted to obtain the Power of Attorney documents.
Review of a document entitled, "Confidential Hospital Occurrence Report, Property of Hospital Attorney" revealed, in part: On 06/01/15 at approximately 10:05 p.m., the Responsible Party came out of Patient #3's room to the nurse's station and demanded to speak with the manager of the floor concerning complaints regarding his sister's care, and that he wanted Patient #3 "out of here." The report also documented that the Responsible Party was at the nurse's station speaking on his cell phone to an unknown party, and the Responsible Party was yelling to the person to whom he was speaking "I want her out of here."
Review of the Grievance Log for 2015 revealed there was no complaint or grievance listed regarding Patient #3.
In an interview on 07/15/15 at 2:15 p.m., S6MR/QA (Medical Records/Quality Assurance) indicated she was the person who coordinated the handling of all complaints and/or grievances that were presented to her by the staff and/or if someone verbally reported a complaint or grievance to her. S6MR/QA confirmed the complaint or grievance does not have to be in writing in order for an investigation to be initiated or conducted. S6MR/QA confirmed she had not received any complaints and/or grievances from the hospital staff or the Responsible Party regarding Patient #3.

In an interview on 07/16/15 at 9:40 a.m., S2DON (Director of Nursing) indicated a complaint or grievance does not have to be in writing for an investigation to be conducted. S2DON agreed the comments made by the Responsible Party on 06/01/15 regarding the dissatisfaction of Patient #3's care at the hospital and wanting Patient #3 transferred out of the hospital would be considered a complaint and/or grievance. S2DON was asked if a grievance investigation was conducted regarding the Responsible Party's requests to have Patient #3 transferred because he was dissatisfied with the care at the hospital, and S2DON indicated the investigation documentation was included in the report entitled "Confidential Hospital Occurrence Report, Property of Hospital Attorney." S2DON confirmed she had not had any verbal or written communication with the Responsible Party since the incident on 06/01/15.
In an interview on 07/16/15 at 9:56 a.m., S1Administrator indicated a complaint or grievance does not have to be in writing for an investigation to be conducted. S1Administrator agreed the comments made by the Responsible Party on 06/01/15 regarding the dissatisfaction of Patient #3's care at the hospital and wanting Patient #3 transferred out of the hospital would be considered a complaint and/or grievance. S1Administrator was asked if a grievance investigation was conducted regarding the Responsible Party's request to have Patient #3 transferred. S1Administrator indicated the investigation documentation was included in the report entitled "Confidential Hospital Occurrence Report, Property of Hospital Attorney." S1Administrator confirmed he had not had any verbal or written communication with the Responsible Party since the incident on 06/01/15.
A review of the documentation with S1Administrator and S2DON, presented by S2DON as all of the documentation regarding the incident on 06/01/15 regarding Patient #3, revealed no evidence that a grievance investigation was conducted and completed by the hospital according to the hospital's policy and procedures for grievances. S1Administrator and S2DON confirmed there was no documented evidence that the policy and procedure for conducting a grievance investigation was done, and should have been.