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Based on interview, policy review and grievance documentation for 4 of 4 patients/patient representatives (Patient #s 3, 11, 12, and 13) that submitted a grievance to the hospital, it was determined that the hospital failed to provide each patient/patient representative with written notice of its decision which contained all of the elements required by hospital policy and this regulation.

Findings included:

1. Review of a policy titled "Patient Complaint/Grievance Management Process," effective 09/02/2011 reflected the following internal requirements: "...The Department of Patient Relations will acknowledge receipt of a grievance within seven business days of the date when the grievance was received in the department. If the grievance cannot be resolved within thirty days of receipt, written notice informing the grievant that the investigation is still ongoing will be sent with an anticipated timeframe for a response...The patient or their representative will be provided with a written response to a grievance, issued on official OHSU [Oregon Health & Science University] letterhead and sent by postal mail or via the grievant's preferred mode of receiving written communication...Every letter will include the name of the hospital contact person, steps taken to investigate the grievance, results of the grievance process and the process completion date."

2. Grievance documentation for Patient #11 was reviewed. A grievance report dated 03/20/2013 reflected the patient submitted a grievance to the hospital regarding care surrounding his/her outpatient surgical procedure. Documentation on the report reflected the patient called the hospital on 04/03/2013 to follow up on the complaint and was told that his/her case was still under review. There was no documentation that a written response was submitted to the patient as required by this regulation. There was no documentation of a written notice informing the patient that the investigation was still ongoing with an anticipated timeframe for a response, in accordance with hospital policy. This was reviewed and confirmed with Interviewee #1 on 05/17/2013 at 1530.

3. Grievance documentation for Patient #12 was reviewed. A letter from the patient to the hospital dated 02/19/2013 reflected a complaint regarding care the patient received after a knee replacement surgery. Review of a written response to the patient from the hospital dated 03/08/2013 lacked documentation of the grievance process completion date, in accordance with hospital policy. This was reviewed and confirmed with Interviewee #1 on 05/17/2013 at 1530.

4. An interview was conducted with Interviewee #1 on 05/17/2013 at 1530. He/she stated that Patient #13's [family member] had submitted a complaint regarding care/monitoring the patient received surrounding an angiogram procedure. During the interview, a written response submitted to the patient from the hospital dated 04/12/2013 was reviewed. The written response lacked documentation of the grievance process completion date.

5. During an interview with Interviewee #2 on 05/17/2013 at 1130, he/she stated an [adult family member] of Patient #3 (a pediatric patient) submitted a grievance to the hospital. The grievance was related to nursing care of the patient's chest tube during a hospitalization in "December or January." Review of a written response to the patient's [adult family member] from the hospital dated 03/15/2013 reflected it lacked documentation of the grievance process completion date. Additionally, there was no documentation of a written notice informing the patient that the investigation was still ongoing with an anticipated timeframe for a response when the grievance was not resolved within 30 days, in accordance with hospital policy.

Based on interview, policy review, and documentation in 1 of 1 medical record (Patient record #3) reviewed of a pediatric patient with a chest tube, it was determined the hospital failed to ensure that the registered nurse (RN) evaluated all of the patient's nursing care needs related to the chest tube in accordance with hospital policy and this regulation.

Findings included:

1. Review of a policy titled NPEOC: Pediatric (Doernbecher Children's Hospital)" effective 11/01/2011 reflected the following internal requirements: "Initial assessment is performed upon the patient's arrival to unit, and includes...Head-to-Toe assessment:..Existing lines, drains and airways...Start of Shift Assessment is performed at the beginning of the nurses' shift...and includes all of the above..." The policy further directed assessments specific to medical/surgical patients as follows: "An assessment within two hours of start of shift; a reassessment every shift and as needed..."

2. An interview was conducted with Interviewee #2 on 05/16/2013 at 1300. He/she stated that the hospital had received a complaint from (pediatric) Patient #3's [family member] related to the care of the patient's chest tube (a drainage tube inserted into the chest to remove abnormal air or fluid that has collected). He/she stated that the patient's chest tube had a stopcock. In order for the patient's lungs to drain effectively, the stopcock had to be in the open position. The patient had received a tPA (tissue plasminogen activator, used to aid the drainage of pleural fluid) instillation into the chest tube. Interviewee #2 stated it was the nurse's responsibility to assess the chest tube and ensure the stopcock was in the correct position after a tPA instillation, and at regular intervals in accordance with hospital policy. Employee A, an RN, was assigned to care for Patient #3 on 12/06/2012 (night shift). At approximately midnight, the RN noticed there was no drainage from the patient's chest tube. However, he/she did not evaluate the stopcock in order to determine whether or not it was in the correct (open) position. At approximately 0400-0500, the patient's [family member] identified that the chest tube was not draining, and the stopcock was not in the open position as it should have been. The RN then verified that the stopcock was not in the open position and notified the patient's physician. Interviewee #2 stated that the RN should have notified the patient's physician as soon as he/she noticed there was no drainage from the chest tube "especially in the case where tPA is used." He/she further stated that the patient's lungs were not able to drain the empyema effectively, and the patient had a longer hospital stay as a result.

3. The medical record for Patient #3 was reviewed. The record reflected the patient was [toddler age] and was admitted to the hospital on 12/04/2012 with a right lung consolidation (lung tissue that has filled with fluid), respiratory distress and empyema (a collection of pus in the space around the lungs). The patient was discharged on 12/26/2012.

Review of nurse progress notes dated 12/04/2012 at 1902 reflected the patient was admitted to the pediatric intensive care unit (PICU) and had a right pleural chest tube placed.

Documentation on a "Transfer Details" record reflected the patient was moved to a medical/surgical unit on 12/06/2012 at 1305.

Nurse flowsheets dated 12/06/2012 at 1800 and 2000 reflected the patient had "40 [milliliters]" and "50 [milliliters]" output (drainage) respectively, from the chest tube. Nurse progress notes dated 12/06/2012 at 2249 reflected that tPA was instilled into the patient's chest tube at 1730. The patient had tachypnea (very rapid respirations), tachycardia (rapid heart rate) and abdominal breathing with complaints of abdominal pain. The patient's condition was documented as stable and responding well to therapy. "Action items" included "...monitor chest tube output."

Nurse flowsheets dated 12/06/2012 at 0000 and 12/07/2012 at 0400 reflected the patient had "0" output from his/her chest tube. Nurse progress notes dated 12/07/2012 at 0505 reflected the patient had tachypnea, tachycardia, and abdominal breathing with complaints of abdominal pain. The patient's stability was documented as "Moderately Unstable." There was no documentation that an assessment had been conducted to determine why the patient's chest tube was not draining, or that the chest tube stopcock was evaluated in order to determine whether or not it was in the correct position. Further, there was no documentation reflecting that the patient's physician was notified at 0000 or 0400, when there was no output from the chest tube as expected.

Physician progress notes dated 12/07/2012 at 0633 reflected "Pneumothorax developed overnight, likely secondary to the stopcock being turned to air."

Review of a chest CT (computed tomography) dated 12/07/2012 at 2102 reflected the patient had a complete right lung collapse and was developing a left upper lobe pneumonia.

4. Interviewee #2 reviewed the medical record for Patient #3 on 05/17/2013 at 1445. He/she acknowledged the record lacked documentation that the RN assessed the chest tube stopcock, and notified the physician timely as he/she should have.