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Based on staff interviews, and review of the grievance/complaint policy, the governing body failed to implement a policy in response to complaints and grievances by patients and/or family members of patients. This involved 5 patients since February 2010.

Findings include:

On 05/11/10 and 05/12/10, a review was conducted of the facility policy titled Patient Complaint, Grievance and Appeal Process which was implemented on 03/21/06 and revised 02/09/09. The policy states the following: The complainant is first referred to the manager or director of the area involved in the complaint. Whenever possible, this process is used to promptly and efficiently resolve complaints. When a patient verbalizes that they are not satisfied with the attempt, more senior leaders in the chain of command are involved and, if necessary, the Director of Customer Service can be contacted. This person is responsible for the coordination and management of complex or serious patient grievances and claims of discrimination, including, but not limited to, allegations of discrimination based on a patient's disability. The Director of Customer Service requests the complaint in writing within 30 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. The written complaint must contain the name and address of the person filing the grievance, must state the problem or action alleged to be discriminatory and the remedy or relief sought. The Director of Customer Service issues a written decision on the grievance no later than 30 days after the receipt of the complaint, with 7 days being the response target.

A review was conducted of the complaint/grievance logs and follow-up process for 01/01/10 through 05/10/10. The facility lacked documentation to the the details of the investigations, lacked written letters to the complainants, and failed follow their policy for time frames for conducting the investigations for the following complaints

a) A complaint was submitted on 02/03/10 by a family member for patient #11 regarding an emergency department (ED) visit on 01/06/10. The complaint alleged no vital signs or physical assessments were conducted by the nurse or physician, and no pain medications were given in the ED. There was no documented evidence of staff interviews conducted or a written resolution to the complainant. A phone call was conducted on 02/05/10 by Staff A apologizing to the complainant.

b) A complaint was received via phone call on 02/13/10 by a family member of Patient #12 who presented to the ED for sutures after a fall, that caused a split on their lips which required stitches. The allegations included the physician was very unprofessional, using profanity, and cut the stitches too short, requiring 2 plastic surgeries for removing the sutures and revision of the patient's lips. An interview with Staff C on 05/11/10, at 11:38 AM,verified the lack of written documentation regarding staff interviews, the resolution, or the written letter of disposition to the complainant.

c) A phone call was received on 02/18/10 by Patient #13's family member regarding an ED visit on 02/16/10. The complainant alleged the physician refused to order antibiotics for the patient's ears. Documentation stated the patient was taken to the pediatrician the next day who stated the patient's eardrums were bulging with redness. The only documentation of an investigation for this complaint stated the patient's parent was called on 02/18/10 and the physician discussed this with the parent.

d) A letter (not dated) from a family member of Patient #14's family member stated the patient presented to the ER on 02/12/10, was there for approximately 6 hours and in the intensive care unit for about 2 hours before being transferred to another hospital. The complaint alleged the care was substandard in regard to the ED physician as the patient presented because of a TIA (mini-stroke) and the physician did not do a neurocheck and did not observe the patient when the patient complained of chest pain. As of 05/11/10, there was no evidence of an investigation into this allegation and no evidence of written response to the complainant. This was verified with Staff A on 05/11/10 at 11:38 AM.

e) A complaint was received from Patient #6's legal guardian on 03/03/10 for care concerns related to the patient's stay in the facility between 02/11/10 and 02/15/10. The concerns voiced by the guardian included being discharged with bedsores, diet pudding like substance, not having enough nourishment or nutrients, not being suctioned frequently enough, being dehydrated, and not following up these concerns. According to documentation provided by the facility and an interview with Staff A on 05/11/10 at 11:40 AM, the facility lacked documented evidence of a thorough investigation into these concerns. There was no evidence of staff interviews or of a written letter of disposition to the guardian in accordance with facility policy.

Interviews conducted with Staff A and C on 05/11/10 at 11:40 AM revealed the staff did not follow the policy and procedure for investigation and documenting grievances or for sending a written response to complainants. Staff A stated complaints are sometimes investigated by the Nursing Manager, the ED physician, or billing, depending on the nature of the complaint. The employee verified the investigations for the aforementioned patients were not done timely, lacked documented evidence of the investigation, and lacked monitoring to ensure the complaints had been investigated.

Based on medical record reviews and staff interviews, the facility failed to meet the nursing needs of 2 of 10 sampled patients (#6 and #2) related to skin breakdown, medical record documentation, and dietary needs.

Findings include:

A medical record review was conducted for Patient #6 during this visit on 05/10/10 through 05/12/10. The record documented the patient presented to the Emergency Department (ED) on 02/12/10 with diagnoses of chest congestion and shortness of breath. The patient was admitted to the facility from the ED and remained in the facility until 02/15/10, at which time the patient was discharged back to another level of care where the patient resided (nursing home).

Patient #6 was admitted with a Stage I (persistent redness) ten by ten centimeter area on the left buttock. The patient was identified at risk for skin breakdown at that time (12 on the Braden scale). The patient remained on bedrest from the time of admission until 02/15/10 when assisted by staff to sit in a bedside chair. At the time of discharge, in addition to the Stage I reddened buttocks, the patient was identified with an excoriated scrotum. The medical record was silent to a description of the size of the left buttock Stage I pressure area, and to the extent of the scrotal excoriation. The medical record was silent to pressure relief devices and preventative interventions to prevent the scrotal excoriation from developing. The patient did have an indwelling urinary catheter throughout this stay, which was discontinued prior to exit. This was verified with Administrative Staff C on 05/11/10 at 11:10 AM who stated staff did not follow facility policy to document the sizes and description of the skin breakdown at the time of discharge. Staff C and A also verified the lack of documentation for preventative interventions to prevent skin breakdown.

A review of the facility policy titled NUR POL 026 Pressure Ulcer Prevention stated the following:
A head to toe skin assessment should be carried out with all clients on admission, daily, and with any change in skin condition. Particular attention should be paid to vulnerable areas, especially over bony prominences. The client's risk for pressure ulcer development is determined by the combination of clinical judgement and the use of a reliable risk assessment tool, Braden Scale for Predicting Pressure Sore Risk (less than or equal to 18). Client's who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction, and shear in all positions and during lifting, turning, and repositioning. For patients identified at risk (below 18 on Braden scale), patients with limited mobility should be turned at least every 2 hours, and suspend heels off bed with use of pillow or heel lifters. All data should be documented at the time of assessment and reassessment. An individualized plan of care is based on assessment data, identified risk factors, and the client's goals. The plan is developed in collaboration with the client, significant others and health care professionals. Interventions include for patients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule. Use pillows or foam wedges to avoid contact between bony prominences. Keep diapers off in bed. Use devices to totally relieve pressure on the heels and bony prominences of the feet. Use lifting devices to avoid dragging clients during transfer and position changes. Use protective barriers. When transferring patients between settings (hospital to home/long term care facility) provide the following information: details of pressure points and skin condition prior to discharge, Stage, site, and size of existing ulcers.






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The medical record for patient #2 was reviewed on 05/11/10. The patient was admitted from a nursing home on 05/07/10 for syncope. The patient is 86 years old. On entrance 05/10/10, Staff A identified this patient as having a reddened coccyx and the patient needed assistance with being fed. Review of the nursing assessments on 5/11/10 failed to reveal documentation of a reddened coccyx.

The nursing assessment revealed the patient had scattered multiple bruising on the right and left arm and leg from fall at home. The nursing notes revealed the patient was self positioning on 05/07/10 and 05/08/10. The notes revealed on 05/09/10 at 8:00 PM, Staff K initiated turning the patient every two hours. The record lacked evidence of an assessment that required two hour repositioning. The skin assessment lacked documentation of a reddened coccyx that the surveyors were told existed on entrance.

Interview with Staff A on 05/11/10, revealed the reddened coccyx was not documented on a nursing skin assessment. Staff A revealed the night shift nurse verbally reported and recorded on 05/09/10 on a document titled "Briefs" (shift to shift report) in the section for pressure ulcers that Patient #2's coccyx was to be monitored closely. Copies of the Brief reports revealed on 05/10/10 the patient's coccyx was reddened.

The nursing policy for pressure ulcer prevention revealed the nurse is required to perform a skin assessment with any change noted in the patient's skin condition with particular attention to vulnerable areas, especially over bony prominences. The record lacked evidence of the reported discovery on 5/10/10 of a reddened coccyx.

Patient #2 was observed on 5/12/10, lying on his/her side with an adult incontinent product on and secured. The patient was incontinent with a small amount of black tarry stool at that time. Staff A presented a care plan dated 5/12/10 at 11:00 AM for impaired skin integrity related to immobility. The wound nurse was consulted on 5/12/10 to visit this patient and documented a nurse trigger to evaluate the patient. The patient's Braden scale number (skin assessment tool) on admission was 21, and decreased to 17 on 5/12/10. (The smaller the number, the more at risk a patient is for pressure sore development). On 05/11/10, the wound care consult nurse (Staff L) described the buttock, wound #3, as not a pressure ulcer and the peri-wound skin as red and blanches adequately. The buttock, wound #3, was described as a small superficial open area between the buttock folds and presents as friction tear versus excoriation related to frequent stool incontinence. The rectum, wound #4, was described as peri rectal skin reddened, intact and blanches well. The perianal redness extends 7 centimeters, no open denuded areas, skin intact and redness related to frequent stool incontinence.

This substantiates the complaint.

Based on medical record reviews and staff interviews, the facility failed to develop a nursing care plan for 2 of 10 sampled patients (#6 and #5) related to skin care and dietary needs.

Findings include:

A medical record review was conducted for Patient #6 during this visit on 05/10/10 through 05/12/10. The record documented the patient presented to the Emergency Department (ED) on 02/12/10 with a diagnoses of chest congestion, shortness of breath, and aspiration pneumonia. The patient was admitted to the facility from the ED and remained in the facility until 02/15/10, at which time the patient was discharged back to another level of care where the patient resided (nursing home).

Patient #6 was admitted with a Stage I (persistent redness) ten by ten centimeter area on the left buttock. The patient was identified at risk for skin breakdown at that time, and remained on bedrest from the time of admission until 02/15/10 when assisted by staff to sit in a bedside chair. At the time of discharge, on 02/15/10, in addition to the Stage I buttock redness, the patient was identified with an excoriated scrotum. The medical record was silent to a care plan for pressure relief devices and preventative interventions for the skin breakdown.

In addition to the skin breakdown, the patient #6 had a diagnosis of active aspiration. During this visit, the patient was evaluated by a speech pathologist who recommended a pudding thickened diet and a modified barium swallow. The barium swallow was not done per the patient's guardian. This was verified with Administrative Staff A on 05/11/10 at 11:10 AM who verified the lack of care planning for this patient in regards to skin breakdown and dietary needs.

A review of the facility policy titled NUR POL 026 Pressure Ulcer Prevention stated the following:
A head to toe skin assessment should be carried out with all clients on admission, daily, and with any change in skin condition. Particular attention should be paid to vulnerable areas, especially over bony prominences. The client's risk for pressure ulcer development is determined by the combination of clinical judgement and the use of a reliable risk assessment tool, Braden Scale for Predicting Pressure Sore Risk (less than or equal to 18). Client's who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction, and shear in all positions and during lifting, turning, and repositioning. For patients identified at risk (below 18 on Braden scale), patients with limited mobility should be turned at least every 2 hours, and suspend heels off bed with use of pillow or heel lifters. All data should be documented at the time of assessment and reassessment. An individualized plan of care is based on assessment data, identified risk factors, and the client's goals. The plan is developed in collaboration with the client, significant others and health care professionals. Interventions include for patients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule. Use pillows or foam wedges to avoid contact between bony prominences. Keep diapers off in bed. Use devices to totally relieve pressure on the heels and bony prominences of the feet. Use lifting devices to avoid dragging clients during transfer and position changes. Use protective barriers. When transferring patients between settings (hospital to home/long term care facility) provide the following information: details of pressure points and skin condition prior to discharge, Stage, site, and size of existing ulcers.





25274

The medical record for Patient #5 was reviewed on 05/11/10. The patient was admitted from a nursing home on 04/05/10 with gastric bleeding and a urinary tract infection. This patient was identified by Staff A on a list of patients who developed wounds while receiving care at this facility. The patient was 84 years old and weighed 65 kilograms. The patient was assessed on admission as having no wounds. The discharged transfer record dated 04/09/10 revealed the patient returned to the nursing home with a Stage II left outer ankle wound and a reddened area 2 centimeters by 1.5 centimeters on the left upper buttock. Although the record revealed a care plan, dated 04/06/10, for potential for infection related to alteration in skin integrity and indwelling catheter as evidenced by altered production of leukocytes and presence of favorable conditions for infections, the record lacked a care plan for potential/actual impaired skin integrity. The nursing notes revealed on 04/08/10 that the patient developed a left upper buttock reddened area measured as 2 centimeters by 1.5 centimeters and barrier cream was applied. The note revealed the patient was incontinent and was wearing an adult incontinence product.

The record revealed patient wound care orders/intervention were initiated on 4/8/10 at 9:30 AM. Prevention orders revealed that with BRADEN risk (skin assessment tool) less than 18 the nurse is to implement the prevention that applies to the patient's individual needs. The nursing staff selected the intervention of turning the patient every 2 hours. The patient's BRADEN scale was recorded as 13 on 04/06/10, 16 on 04/07/10, and 04/08/10 as 15.

On 4/9/10 at 10:30 AM the nursing notes revealed a Stage II left outer ankle wound with bleeding. The facility failed to follow their skin/wound protocol for prevention when the patient has a Braden scale risk below 18 which state: keep diapers off the patient while in bed and suspend the patient's heels off bed with use of pillow or heel lifters. The patient returned to the nursing home on 04/09/10 with a reddened area on the buttock and Stage II wound on ankle acquired during admission from 4/5/10 to 4/9/10. This was verified with Staff A and C on 05/11/10.

This substantiates the complaint.