HospitalInspections.org

Based on review of the hospital's grievance process and six grievance files, it was determined that the hospital failed to include the required information in the final resolution letter for 3 of the 6 grievances received in the past six months.

Letter #1: A patient identified two separate grievances in their letter, however one of the issues (patient was medicated intravenously after stating she did not want the medication) was not investigated (no evidence in file, Patient advocate stated being unaware of this second grievance). The final letter did not include an investigation process for either grievance.

Letter #2: A patient stated they were assaulted by another patient. The file did not show an investigation was completed. The final letter failed to include steps taken or the results of the grievance process.

Letter #3: The file did not include an investigation process regarding a patient questioning treatment. The final letter did not include a process of investigation, the result, or the date of completion for this grievance.

In summary, the letters that were sent to the patients were non-specific to their grievances and did not include any steps in the investigation process. There was also no information in the files to validate that an investigation was performed.

Based on review of 7 open and 5 closed records it was determined that the facility failed to provide interpreter services for Patient #11 to obtain informed consent, allow the patient the right to refuse or request treatments, to establish a baseline including a medical history or to determine their understanding of the discharge instructions.

Patient #11 was a 30+ year old patient that presented to the Emergency Department (ED) after a suspected overdose of an illicit drug. Documentation by the Emergency Medical Service that brought the patient to the ED and nursing staff at the hospital stated the patient spoke Spanish only.

A physician note timed for 7 hours after the patient arrived stated "a staff member recognized patient and found same name under a different medical record number. On review of this chart, patient has a history of seizures, will check medication level and load patient". No baseline was ever established with the patient through an interpreter even though the physician documented the "patient was resting comfortably" and was "calm and cooperative" a few hours after arrival.

A note by the discharging nurse stated "still speaks no English, but follows direction to sit up". However, the nursing assessment upon arrival to the ED listed the patient's preferred language as 'English' and under the heading of 'Interpreter called', the answer was 'N/A'.

No documentation was found to indicate that an interpreter was called at any time during the patient's stay. Nursing notes state the patient declined speaking to the Social Worker, and refused to sign the discharge paperwork. Without the use of interpreter services, it cannot be determined whether the patient refused this information due to a language barrier and therefore was possibly discharged without the appropriate information needed for follow-up.

Furthermore, the discharge instructions were printed in English.

Based on review of 7 open and 5 closed records, including 3 restraint records, it was determined that the hospital failed to release two patients (#11 & #12) from restraints at the earliest possible time.

Findings include:

Patient #11 presented to the Emergency Department (ED) after a suspected drug overdose. While in the ED, the patient had a seizure and during the postictal period (altered state of consciousness after an epileptic seizure) started thrashing around and was immediately placed in 4-point restraints and medicated with an antipsychotic medication.

The physician face to face one hour after patient was placed in restraints stated that the patient was "Quiet, sleeping", however it was documented that the intervention should be continued. Further review of the restraint record indicated that the patient continued to be in restraints for two hours even though the neurological assessments listed his/her affect/behavior as calm during those two hours.

Patient #12 was a 30+ year old patient who presented to the ED with delirium after illicit drug use. Per medical record documentation, the patient was diaphoretic (sweating) and flailing on the stretcher and immediately placed in 4-point restraints. Review of the restraint record revealed several notations indicating that the restraints were only partially removed even when the patient was calmer. For example:

"Left leg restraint removed per MD, patient still combative though calmer".

"Right arm restraint discontinued".

"Right arm, right leg restraints discontinued per patient request and negotiation with nurse".

Further documentation revealed a physician note that stated "Patient became much more lucid. We were able to remove restraints. Still appears under the influence but has been very cooperative". However, the restraint assessment and monitoring log reveals documentation that patient continued to be in 4-point restraints for approximately 8 hours after the physician wrote that note.

In summary, neither patient #11 nor patient #12 were released from restraints as soon as they ceased exhibiting dangerous or injurious behaviors. In addition, restraining a patient who had just had a seizure increased the risk of aspiration or choking while releasing restraints one limb at a time increased the risk for injury from falling out of bed.

Based on review of 7 open and 5 closed medical records it was determined that the hospital staff failed to properly execute a consent form for 1 of 4 patients undergoing a procedure requiring consent.

Patient #1 was a 70 + year old patient who presented to the hospital with an abscess. Patient #1 had several procedures done while inpatient. On the 11th day of admission, patient #1 had an upper gastrointestinal (GI) endoscopy due to having dark stools. Review of patient's chart revealed a signed consent dated the day of the patient's procedure. This consent did not identify the procedure to be performed on the consent form, therefore, not properly documenting patient consented to the procedure.

Based on review of hospital policies and procedures, staff interviews, and unit observations of medication rooms, it was determined that the hospital failed to promptly resolve and reconcile a discrepancy of a controlled substance, schedule II, for greater than 2 days.

Observation of care in the Critical Care Unit (CCU) was done including the medication room on the unit. While reviewing the medication room on 5/8/19, the icon of a medication discrepancy was noted on the screen of the automated medication cabinet (Pyxis). The staff were asked the process of reconciling such discrepancies. Staff stated that two registered nurses, one being the charge nurse, could have corrected the count. In addition, at change of shift the ongoing and off going Charge Nurses were to check and correct any discrepancy that may have occurred during the prior 12 hour shift. The nurse was asked to show the information for this discrepancy, the screen showed that the medication discrepancy occurred on Monday 05/6/2019 at 0907 and remained unresolved as of the time of the survey.

The hospital's nursing and pharmacy staff failed to recognize and resolve the discrepancy, despite the lapse of 4 shift changes and greater than 48 hours. This contradicts staff statements and the hospital policy titled: Controlled Substance Discrepancy Resolution in Unit Based Cabinets (Pyxis) revised May, 2015.

Based on reviewed policies and procedures, quality data metrics, staff interviews, and observations of care conducted in the Emergency Department (ED) it was deemed that staff failed to adhere to proper hand hygiene standards established by the hospital and infection control standards.

During an observation of care in the ED, a Registered Nurse (RN) was observed entering a patient room without hand washing or using alcohol-based hand sanitizers (ABHS). The RN was observed entering the patient room with supplies in both hands. The RN then placed supplies on the table, then reached for gloves and began patient care. No hand hygiene was observed. Gross breaks in standardized infection control practices were witnessed.

Review of quality metrics and interview with the infection control practitioner reflect that there is a persistent lack of staff adherence to hospital set standards in hand hygiene. The hospital was able to provide data and metrics regarding hand hygiene surveillance; however, there was a lack of evidence of intervention to address and improve current deficient practices.

Based on review of 5 closed and 7 open medical records it was determined that the hospital staff failed to obtain an operative report immediately following surgery for patient #1.

Patient #1 was a 70 + year old patient who presented to the hospital with an abscess. On patient #1's third day of admission, patient #1 underwent a surgical procedure. The surgery ended at around 15:26. The surgeon's post-operative report was dictated the following day at 15:15 about 24 hours later. A brief post-operative note was also not found.

Based on the review of policies and procedures, observations of care, and review of personnel files it was determined that the hospital failed to establish a systematic and objective process by which the respiratory staff's (RTs) clinical knowledge and skills are evaluated on an ongoing bases, beyond new hire orientation, for one of four respiratory personnel files. One of four RT personnel files lacked appropriate documentation of staff competencies to fulfil job requirements.

Four respiratory therapists were randomly selected for review of credentialing and evaluation. Of the four files RT #1 and #2 were employed at this hospital less than six months, RT #3 less three months and RT# 4 had greater than 12 years of service. RT #4's personnel file lacked documentation of ongoing or annual competency. After surveyor request for this information, the hospital submitted six forms of evaluation for RT #4. The six forms spanned a three year period and had identical check marks and initials in the exact same order on all six pages except for the date on the top right corner. The forms lacked signatures of the evaluator and the RT being evaluated.

Survey team enquired of the striking similarities of all six forms with hospital leadership, who investigated the process with the respiratory department manager. The respiratory leadership used a pre-checked and pre-initialed form to conduct on going evaluations of staff. Staff evaluations were started with the assumption that staff are meeting hospital standards, hence the prefilled form.

The hospital failed to provide a policy and procedure by which RT staff are objectively evaluated, skills maintained, and clinical competencies validated on a regular basis. In addition, staff evaluations were maintained by the department manager that completed the evaluation. There is leadership assessment of the quality of the evaluation process, and no provision for verification of the objectivity of the evaluation process or skills and techniques covered.