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Based on review of the facility's grievance response letter to a complaint of neglect, policy review, and staff interview, the facility failed to ensure that the complainant for Patient #1, one (1) of one (1) patients reviewed, was informed of the results of the facility's grievance process within the timeframe allowed by its policy.


Findings include:


Review of the facility's grievance response letter, sent to Patient #1's grandfather on 12/17/2015, revealed that the facility was informed of the complaint of neglect by the grandfather on 12/09/15.


Review of the facility's "Patient Complaint and Grievances" policy, reviewed/revised 08/2014, revealed: l. Purpose: To establish guidelines for prompt resolution of patient complaints and greivances and the contact information that must be provided to the patient... IV. General Greivance Guidelines: A. Handle promptly (within 7 days) or provide written explanation and additional written response with the number of days it will take... "

This finding was discussed with the Chief Nursing Officer during an interview on 12/18/2015 at 1:15 p.m. She agreed with the findings and stated that the issue had been corrected prior to the time of survey

Based on medical record review, policy review, and staff interview, the facility failed to ensure one (1) of one (1) patients reviewed, Patient #1, was free from neglect by failing to ensure a physician ordered Sequential Compression Device (SCD) was applied to the patient's lower extremities in a timely manner.


Findings include:


Record review for Patient #1 revealed she was a 16-year-old female who arrived at the hospital's emergency department (ED) on 11/15/2015 after being an unrestrained driver in a Motor Vehicle Collision (MVC). The patient was received as a transfer from a different hospital for a higher level of care after she was noted to have spinal fractures. Fractures included: Thoracic six (6) bust fracture with 15% spinal canal narrowing; 10% lateral compression fracture of Thoracic seven (7); right transverse process fracture of Thoracic six (6) and Thoracic seven (7); Cervical spine-right parietal scalp hematoma; and Cervical spine-hairline non-displaced fracture of Cervical seven (7). Review of physician's orders revealed a 11/16/2015 physician's order for a Sequential Compression Device (SCD) to be applied to the patient's lower extremities. The SCD sleeves (hoses) were not applied to the patient's lower extremities until 11/19/15. There was no documented evidence to explain why it took three (3) days to apply the SCD.


Review of a Nurse Practitioner's (NP) progress note dated 11/19/2015 revealed, "..patient received oxygen 2-3 liters per minute per nasal cannula as needed. The patient continued to have oxygen supplementation required for decreased saturation when the oxygen is removed. She was sent for Dopplers of bilateral lower extremities this am, results are pending and Computerized Tomography (CT)." The radiologist notified the NP that patient had right lower lobe sub-segmental Pulmonary Embolus finding on CT scan. The patient was discharged home on 11/25/2015.


Review of the facility's "Sequential Compression Device (SCD), Application of" policy, revised 1/23/2015, revealed: "I. Purpose: To provide guidelines for safe application of SCD sleeves to patient. SCDs help to promote the flow of blood through the vascular system of the lower extremities and assist in reduction of thrombi (blood clot) formation. V. Procedure: ... J. Remove sleeves every shift for thirty (30) minutes. This allows staff to wash skin, lubricate and assess for skin breakdown of lower extremities. Reapply sleeves. K. Document in the patient's electronic health record (EHR) placement of the hose and functioning/cycling of the pump. Continue to document at least once per shift until patient is discharged or the order is discontinued...."


These findings were discussed with the Chief Nursing Officer on 12/18/2015 at 1:15 p.m. She confirmed these findings and stated that this deficiency had been corrected.

Based on record review and staff interview, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated nursing care for Patient #1, one (1) of one (1) patients reviewed, from 11/16/2015 until 11/19/2015.


Findings include:


Record review for Patient #1 revealed the patient was admitted to the facility with multiple spinal fractures on 11/15/2015 following a motor vehicle collision. On 11/16/2015 the physician ordered a Sequential Compression Device (SCD) to be applied to the patient's lower extremities. There was no documented evidence that the SCD was provided until 11/19/15.

Review of a Nurse Practitioner's (NP) progress note dated 11/19/2015 revealed, "..patient received oxygen 2-3 liters per minute per nasal cannula as needed. The patient continued to have oxygen supplementation required for decreased saturation when the oxygen is removed. She was sent for Dopplers of bilateral lower extremities this am, results are pending and Computerized Tomography (CT)." The radiologist notified the NP that patient had right lower lobe sub-segmental Pulmonary Embolus finding on CT scan.


A physician's progress note dated 11/22/2015 revealed that Patient #1 had a small sub-segmental pulmonary embolus. The patient was medicated with Heparin (blood thinner) beginning on 11/21/2015. The patient was discharged home with Home Health Services on 11/25/2015.



These findings were discussed with the Chief Nursing Officer on 12/18/2015 at 1:15 p.m. She confirmed the findings that a RN had not supervised and evaluated nursing care for Patient #1.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure that one (1) of one (1) patients reviewed, Patient #1's, medical record contained documentation of provision of Sequential Compression Device (SCD) ordered in a timely manner.


Findings include:


Cross Refer to A145 for the facility's failure to ensure documented evidence of SCD application was entered into the patient's medical record and available to the physician in a timely manner.