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Based on facility policy review, facility documentation review, medical record review and interviews, the hospital failed to conduct a through investigation of a grievance/complaint and provide a resolution to the patient, for one (#2) of two patients sampled for grievances.

Findings included:

Review of policy Patient Complaint and Grievance Policy, last revised 03/2023, reflected: ... the concern or grievance will not be resolved or if the investigation will not be completed within 7 business days, the acknowledgement will also inform the customer that the investigation continues to be in process and an additional written response with resolution will be provided within approximately 30 days ...A grievance is considered closed when the customer is satisfied with the actions taken on their behalf or the facility has taken appropriate and reasonable actions (including appropriate escalation to leadership) to resolve the grievance even if the customer remains unsatisfied with the facility's actions.

Review of the facility grievance /complaint log dated 3/28/23 showed Patient #2 filed a grievance. The log reflected the grievance was related to comfort during tests and treatment, and quality of care. The log showed a resolution date of 5/01/2023.

A review of the grievance filed by Patient #2 dated 3/24/23 reflected a concern related to a medical suction system failure which she reported to several staff members during her hospitalization. The suction malfunction was not addressed in a timely manner, resulting in a potentially avoidable surgery.

A review of the facesheet in the medical record for Patient #2 reflected an admission date of 2/13/23 with a diagnosis of small bowel obstruction (SBO).

Upon review of physican's orders in the medical record, an order dated 2/13/23 10:48 AM was discovered, for Nasogastric (NG)/Orogastric Tube Insertion, routine, Low-Intermittent Suction.

Review of the GI (gastrointestinal) shift assessment documentation reflected an NGT (nasogastric tube) was inserted on 2/13/23 at 12:28 PM. Further review of the assessments revealed no documentation the low intermittent suction was running until 2/14/23 10:30 PM.

Review of Patient #2's output record for the NGT (nasogastric tube) showed no documented output volume until 2/15/23 at 8:00 AM.

A review of the physician progress note in the medical record, dated 2/14/23 6:47 PM reflected a 24 hour output of "0" from 2/13/23 5:55 PM to 2/14/23 5:54 PM.

A review of the operative report in Patient #2's medical record, dated 2/14/23 8:36 PM, revealed a post operative diagnosis of SBO, closed loop with small bowel ischemia. Further review showed the following:
Procedures:
1. Diagnostic laparoscopy (a procedure used to check the organs in the abdomen).
2. Exploratory Laparotomy.
3. Repair of incidental Cecotomy (incision into the cecum, a pouch connected to the junction of the small and large intestines).
4. Appendectomy (surgical removal of the appendix, a small organ that comes out from the first part of the large intestine).
Complications: Trocar placement into a distended cecum upon entry into the abdomen.
Intraopeartive findings:
1. Left upper quadrant port site was initially placed in the cecum.
2. Small bowel noted in the pelvis to be ischemic and had to be resected.
3. The patient had a very adherent appendix to the cecum, that tended to be tenting it and retracting it along the side wall, this was resected.
Review of a post operative physican's order dated 2/14/23 8:24 PM, reflected Nasogastric/Orogastric Tube Care, routine, Low-Intermittent Suction, Constant Indicator.

Further review of the output documentation in the medical record dated 2/14/23 and 2/15/23, revealed there was still no documented output until after 8:00 AM on 2/15/23.

On 8/28/23 at 11:12 AM an interview was conducted with Staff A during the record review. Staff A confirmed there was no documented output from the NGT prior to 8/15/23. Staff A said they are required to document the output.

Review of the Corrective Work Order dated 2/15/23 revealed the following:
Suction not working in 3720
Priority: Non-Urgent 2 hours to 14 days
Status: cancelled
Sub status: referred to correct department
Comments: spoke to Staff A; she needs to call clinical engineering.
Request remarks: low intermittent suction not working, patient has orders

During an interview on 8/28/2023 at 11:56 AM, the risk manager said because of the lack of documentation on the output from the NG (nasogastric) tube suction, the complaint/grievance was sent to the claims department.

On 8/28/23 at 1:30 PM a telephone interview was conducted with Patient #2. Patient #2 said she has not received any further communication from the hospital regarding her complaint.

On 8/28/23 at 2:03 PM an interview was conducted with a surgeon, Staff B. Staff B said conservative management of a bowel obstruction is decompression with an NGT. He stated 80% of small bowel obstructions resolve with decompression and 20% require surgery. Without decompression she would need surgery. Necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) is a potential complication when there isn't any decompression. The amount of edema (sweling) in the abdomen complicated the procedure and the trocar (a surgical instrument) went into the displaced cecum causing an injury that had to be repaired. There would have been an 80% chance she wouldn't have required surgery with abdominal decompression.

On 8/28/23 at 2:19 PM an interview was conducted with Staff C, nurse manager. Staff C said the charge nurse said it was handled, so there wasn't an investigation.

During an interview on 8/28/2023 at 2:24 PM, the claims manager said that both herself and the clinical investigator reviewed Patient #2's medical record and both agreed there were no discrepancies in her care. During the same interview, the claims manager revealed she did not send a resolution letter to the patient because the case is still active/open despite the grievance log showing the case is closed.

Based on record review, documentation review, interviews, and policy review the hospital failed to ensure medical suction equipment was maintained in a manner to ensure patients requiring suction received the care and services necessary for treatment of a small bowel obstruction (SBO) for one patient (#2) of two patients sampled.

Findings included:

A review of the facesheet in the medical record for Patient #2 reflected an admission date of 2/13/23 with a diagnosis of small bowel obstruction (SBO).

Upon review of physican's orders in the medical record, an order dated 2/13/23 10:48 AM was discovered, for Nasogastric (NGT)/Orogastric Tube Insertion, routine, Low-Intermittent Suction.

Review of the GI (gastrointestinal) shift assessment documentation reflected an NGT (nasogastric tube) was inserted on 2/13/23 at 12:28 PM. Further review of the assessments revealed no documentation the low intermittent suction was running until 2/14/23 10:30 PM.

Review of Patient #2's output for the NGT showed no documented output volume until 2/15/23 at 8:00 AM.

A review of the physician progress note in the medical record, dated 2/14/23 6:47 PM reflected a 24 hour output of "0" from 2/13/23 5:55 PM to 2/14/23 5:54 PM.

A review of the operative report in Patient #2's medical record, dated 2/14/23 8:36 PM, revealed a post operative diagnosis of SBO, closed loop with small bowel ischemia. Further review showed:
Procedures:
1. Diagnostic laparoscopy (a procedure used to check the organs in the abdomen).
2. Exploratory Laparotomy.
3. Repair of incidental Cecotomy (incision into the cecum, a pouch connected to the junction of the small and large intestines).
4. Appendectomy (surgical removal of the appendix, a small organ that comes out from the first part of the large intestine).
Complications: Trocar placement into a distended cecum upon entry into the abdomen.
Intraopeartive findings:
1. Left upper quadrant port site was initially placed in the cecum.
2. Small bowel noted in the pelvis to be ischemic and had to be resected.
3. The patient had a very adherent appendix to the cecum, that tended to be tenting it and retracting it along the side wall, this was resected.
Review of a post operative physican's order dated 2/14/23 8:24 PM, reflected Nasogastric/Orogastric Tube Care, routine, Low-Intermittent Suction, Constant Indicator.

On 8/28/23 at 11:12 AM an interview was conducted with Staff A during the record review. Staff A confirmed there was no documented output from the NGT prior to 8/15/23. Staff A said they are required to document the output.

Review of the Corrective Work Order dated 2/15/23 revealed the following:
Suction not working in 3720
Priority: Non-Urgent 2 hours to 14 days
Status: cancelled
Sub status: referred to correct department
Comments: spoke to Staff A; she needs to call clinical engineering.
Request remarks: low intermittent suction not working, patient has orders

On 8/28/23 at 1:30 PM a telephone interview was conducted with Patient #2. Patient #2 said she told the night nurse the suction wasn't working on the night she was admitted to the room. The nurse got it working for a few seconds after she tried putting it on continuous suction. But then it stopped working again. The night nurse told the day nurse (Staff E) it wasn't working during the shift change report. Staff E said he told the charge it wasn't working. No one came in the room to fix the suction, and she continued in severe pain with abdominal distention. After several more hours and no one fixing the suction, she complained to Staff E again and asked him to call the doctor. He brought the phone in with the hospitalist on the other end. The hospitalist asked her what she wanted him to do for her. She told him the suction was not working and she now needed surgery. He told her it can take several days for a SBO to resolve. She asked him to notify the surgeon. Still no one came in to fix the suction, and she didn't see a doctor all day. Finally, Staff E called the surgeon who came to the room shortly after, and took her to emergency surgery about a half an hour after that. After the surgery she went back to her room and slept most of the night. When she woke up around 6:00 AM the suction was still not working. She told the nurse who tried moving it to the other side of the panel, but it still didn't work. The nurse told the charge nurse, who then came in and said she was already aware the suction wasn't working. Patient #2 said she asked the charge why she didn't move her to another room if she knew it wasn't working. The charge nurse told her it was because there wasn't another room to move Patient #2 to, or they would have already moved her. Thankfully, within a few minutes someone finally came in and fixed the suction. The staff member who fixed it said they had just received the work order today.

On 8/28/23 at 2:03 PM an interview was conducted with a surgeon, Staff B. Staff B said conservative management of a bowel obstruction is decompression with an NGT. He stated 80% of small bowel obstructions resolve with decompression and 20% require surgery. Without decompression she would need surgery. Necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) is a potential complication when there isn't any decompression. The amount of edema (sweling) in the abdomen complicated the procedure and the trocar (a surgical instrument) went into the displaced cecum causing an injury that had to be repaired. There would have been an 80% chance she wouldn't have required surgery with abdominal decompression.


Review of Equipment Work Order History log for Clinical Engineering, dated 02/01/2023- 08/28/2023, revealed the hospital never entered a work order into the computer for the faulty suction in Patient #2's room.

During an interview on 08/28/2023 at 2:15 PM the Clinical Engineering Service Team Lead stated she looked in the log of work orders from February and there was not a work order filed for the room Patient #2 was residing in. She also stated she asked her staff if they recalled the floor calling about checking the gas in that room and they all said no.

On 9/1/23 at 11:38 AM an interview was conducted with Staff F, charge RN (registered nurse). She has been a charge nurse on 3 North since October 2022. Staff F said she didn't recall that situation at all. Staff F said she would put an order in for it to be looked at by facilities. It can take a few hours to a few days for thenm to address it. It should be immediate; upon them receiving notification of it. Someone would have to show up. Staff F said if that didn't happen she would notify the AOD (administrator on duty).

Review of policy [Medical Equipment (ME) Management Plan], policy #BC-EOC-106 and Issued Date 02/2023 ... Should a piece of medical equipment malfunction or fail, hospital staff should first ensure the safety of the patient, remove the piece of equipment from service, label it and notify Clinical Engineering ...Clinical engineering documents and maintains all non-high risk equipment maintenance records for the facility and their affiliates. Reports of the completion rate of scheduled inspections and maintenance are presented to the EC committee. The minimum acceptance monthly completion rate for non-high risk medical equipment is 100%.