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Based on record review and interview the facility failed to ensure the patient is notified of grievance investigation resolution, per facility policy in 1 of 1 grievance investigations reviewed (1). This deficiency directly affects Patient #1 and potentially affects all persons who file a complaint.

Findings include:

The facility policy titled "PATIENT COMPLAINTS AND GRIEVANCES" dated 7/11/16 id # 3213 was reviewed on 10/17/17 at 11:50 AM. This document states under "PURPOSE" on page 1 "This policy provides a mechanism for initiation, review and resolution of patient complaints and grievances." Under "DEFINITIONS" a complaint includes "Post-encounter verbal communications that would routinely have been handled by staff present, if communications had occurred during the stay/visit are considered a complaint rather than a grievance." This document states on page 5 under "PROCEDURE" "IV. Staff members unable to immediately resolve complaints at the point of care will involve the department director or designee for investigation and resolution of the issue, as a grievance. Patients will be provided with a projected time of response if unable to resolve the issue immediately." "VI. Grievances will be forwarded to the director of the department/clinic manager involved and are to be addressed as quickly as possible. If unable to investigate and resolve the grievance in 7 business days from receipt, a written or verbal notice of acknowledgment will be communicated to the patient/designee. This will be done to acknowledge the grievance, clarify the issue(s), inform the complainant as to who will investigate the concerns and provide them with a time frame for follow up to the resolution(s)." "VII. All complaints/grievances are to be entered into the online Aspirus Patient Safety and Event Reporting system by the staff person receiving the complaint or the Patient Relations Coordinator including actions taken to resolve as well as service recovery efforts, accurately identifying the issue(s) as either a complaint or a grievance. All correspondence including initial correspondence of the complaint/grievance as well as related written follow up will be attached to the event, electronically, when able." "XIV. Resolution information will be provided to the patient/patient's representative in a manner that is understandable to them." "XV. The patient/designee filing the grievance will be provided written notification of the outcome of the grievance."

Per phone call with Patient #1's spouse on 10/13/17 patient's spouse spoke with unit director (cardiac telemetry unit) and patient's spouse about Patient #1 acquiring wound on coccyx while in hospital 7/24/17-7/29/17. When asked if patient's spouse heard a response back from facility written or verbally patient's spouse responded "never a word". When asked if Patient #1's spouse filed a formal grievance spouse responded "I didn't know I could".

On review of "Patient Advocate Intake Notes" dated 8/10/17 entry #5 with a number of 31132 documented Patient #1 name and medical record number documented "heart surgery 7/25/17 now has decubitus ulcer." and "dc'd (discharged home) with home care. Referral to wound clinic for gluteal wound. Saw Dr. (Staff L) today being referred to Surgical Associates for deep gluteal wound." Patient Advocate note also stated "Contacted Teresa re this. She will open a PCE "just in case". Reviewed some of record-skin breakdown noted on 7/28/17. Was followed up as out pt (patient). Will speak with pt (patient) and (spouse) tomorrow and see what they are thinking." There is no documentation of follow up or contacting of Patient #1 or spouse. The facility document containing complaint and grievances was reviewed on 10/17/17 at 11:00 AM provided by facility for the CTU (cardiac telemetry unit) 7/22/17-10/17/17 Patient #1 and/or spouse is documented as a complaint.

Based on record review and interview, nursing staff at this facility failed to assess patients with wounds according to facility policy in 3 out of 9 patients with skin integrity issues out of a total of 20 medical records reviewed (Patient #1, 12, 19).

Findings include:

The facility's policy titled, "Skin/Wound Care Protocol," #03-07-1915, dated 3/16/2016 was reviewed on 10/17/2017 at 11:45 AM. The policy states in part, "Sensory Perception: Pressure Reduction a. Inspect skin at least every 8 hours in the acute care setting..." The policy addresses documentation as, "Documentation in appropriate areas in [name of electronic medical record]."

The facility policy titled "SKIN/WOUND CARE PROTOCOL" dated 3/16/16 id #1204 was reviewed on 10/19/17 at 11:45 AM under "PURPOSE" states "To promote prompt evaluation and intervention of any changes in skin integrity during the hospital stay." Facility policy continues on page 18 "Care of Category/Stage I and II Pressure Ulcers" algorithm states "pressure ulcer present on admission?" if answer is "no" "Measure & photo. Complete Patient Safety Event. Initiate Care Plan."

Patient #1's medical record was reviewed on 10/17/17 at 12:45 PM with Registered Nurse/Epic Trainer F who confirmed the following findings: Patient #1 was 67 years old was admitted to the facility on 7/24/17 for open heart surgery. Open heart surgery was performed on 7/25/27 which included a sternotomy (mid chest) incision as well as incision sites for vein harvest in right leg. According to nursing flow sheets from day of admission until 7/28/17 at 10:40 PM Patient #1 had "WDL" (within defined limits) in skin assessments. On 7/28/17 at 10:40 PM nursing flow sheet indicates a change in skin integrity and stated "excoriated area on coccyx". Mepilex (cushioned foam dressing) applied". There are no skin integrity issues identified in the flow sheet section titled, "LDA," (lines, drains,airway). There is no documentation addressing "excoriated area on coccyx" after the application of the dressing on 7/28/17 at 10:40 PM. There is no photo documentation of the area, no completed "Patient Safety Event" documenting the area and no problem initiated on care plan as per "SKIN/WOUND CARE PROTOCOL" instructions. Patient #1 discharged on 7/29/17. There is no direction for monitoring area on coccyx or changing the dressing on Patient #1's discharge instructions. Admission assessment from home health nurse first visit dated 7/31/17 described the wound and stated "The wound was not noted in the discharge paperwork sent to (home health agency) from the hospital."

An interview was conducted with Chief Nursing Officer N on 10/17/17 at 5:40 PM when questioned as to if staff would be expected to complete an occurrence or incidence form upon assessing a new skin condition Chief Nursing Officer N replied "No, they wouldn't have to."






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Patient #12's closed medical record was reviewed on 10/17/2017 at 1:12 PM accompanied by Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #12, 94 years old, was admitted to the facility on 9/5/2017 with an ischemic (decreased blood supply caused by partial or total blockage of an artery) right foot and pneumonia. According to nursing flow sheets, between Patient #12's admission on 9/5/2017 and the nursing assessment of skin integrity on 9/8/2017 at 6:11 AM there were no noted skin issues in the "diaper area."

On 9/8/2017 at 6:11 AM a nurse documented that Patient #12 complained of tailbone pain and a mepilex dressing (cushioned foam type dressing) was applied. There is no description of the tailbone area (no information regarding redness, impaired skin integrity, measurements) in any flow sheet entry between 9/8/2017 through discharge on 9/12/2017. There are no imparities identified in the flow sheet section titled, "LDA," (lines, drains, airway).

There is no documentation indicating that the dressing had been changed or when it was due to be changed. between application of the dressing on 9/8/017 through Patient #12's discharge on 9/12/2017. There is no direction for changing the dressing on Patient #12's discharge instructions. There is no picture on file of the affected tailbone area. There is no documented skin assessment between 9/8/2017 at 11:00 PM until 3:00 PM on 9/9/2017.

Per interview with Clinical Lead Registered Nurse G on 10/17/2017 at 11:38 AM, Nurse G stated that skin assessments are to be completed and documented every 8 hours in the flow sheet of the electronic medical record. If there is a wound or fragile skin at risk of becoming a wound/ulcer, the patient should have a care plan opened. If an ulcer develops during a patient's admission, a picture is taken of the area, there should be documentation on the flow sheets describing the area, a care plan should be opened and the wound nurse or provider should be consulted.

Patient #19's closed medical record was reviewed on 10/17/2017 at 4:05 PM accompanied by Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #19 was admitted to the facility on 10/3/2017 with right lower leg ischemia. At 6:00 PM on 10/3/2017 the nursing flow sheet skin integrity section indicates that Patient #19 has a fully healed right groin incision from a surgery during a prior admission (cardiac catheterization on 9/14/2017).

On 10/5/2017 Patient #19 had another surgery through the right groin artery (endarterectomy-a procedure that removes plaque buildup from inside the arteries) resulting in a new incision. The skin section of the nursing flow sheets from 10/5/2017 at 7:10 PM through the time of discharge on 10/8/2017 indicate that Patient #19 has dry flaky skin on the lower extremities but there is no mention of a new surgical incision in the right groin. There are no documented nursing assessments of a new surgical incision after the 10/5/2017 surgery in the skin section of the nursing flow sheets. There are no entries in the LDA section of the flow sheet. Patient #19 was discharged on 10/8/2017 with no documented skin assessment between 10/7/2017 at 10:37 PM and the time of discharge on 10/8/2017.

Per interview with Clinical Informatics Specialist F on 10/17/2017 at 1:30 PM, the LDA (lines,drains,airway) area is for documentation of tubes and wounds as well and is a "place keeper" to identify the presence of an intravenous/central line, any type of surgical drain, mechanical means to keep the airway open, and any other tubes, wounds/pressure ulcers a patient might have. The LDA is a fluent list and when something is on this list it follows that patient from admission to admission until the issue is resolved.

Based on record review and interview, nursing staff at this facility failed to keep current care plans that reflect the medical needs and nursing care of the patient with skin integrity impairments in 7 of 9 medical records out of a total of 20 medical records reviewed (Patient #1, 4, 9, 10, 12, 19, and 20).

Findings include:

The facility policy titled "NURSING CLINICAL DOCUMENTATION GUIDELINES" dated 5/7/17 id #15495 was reviewed 10/19/17 at 11:30 AM. This document states under "DEFINITIONS:" "Expected Outcome-Intended result of the care that is delivered." Continues on page 2 under "GUIDELINE:" "I. Documentation will be patient-centered and interdisciplinary, showing the care and treatment delivered and the patients' progress related to nursing interventions, nursing outcomes and nursing diagnosis in meeting expect outcomes.", "b. Care plans are required for each inpatient, and are the responsibility of the Registered Nurse. Care plans are based on goals, evaluated for progress, clinically relevant and current." On page 3 under section "VII" "a. All documentation will be either electronic or written legible, in ink, recording all pertinent data in a concise manner including:" "V. Treatment goals, plan of care, and revisions to the plan of care." On page 5 under "VIII. Documentation elements are as follows:" "d. Care plans. ii. 1. The care plan is to be reviewed every shift for clinical pertinence and updated daily." "v. The care plan ensures that the patient's progress is monitored consistently by all caregivers by having parameters identified for the expected patient outcomes. vi. Documentation must demonstrate progress toward the goal, or show a change in the patient condition."

The facility policy titled "SKIN/WOUND CARE PROTOCOL" dated 3/16/16 id #1204 was reviewed on 10/19/17 at 11:45 AM under "PURPOSE" states "To promote prompt evaluation and intervention of any changes in skin integrity during the hospital stay." Facility policy continues on page 18 "Care of Category/Stage I and II Pressure Ulcers" algorithm for having found a new skin impairment states "pressure ulcer present on admission=no. Measure & photo. Complete Patient Safety Event. Initiate Care Plan."

Patient #1's medical record was reviewed on 10/17/17 at 12:45 PM with Registered Nurse/Epic Trainer F who confirmed the following findings: Patient #1 was admitted to the facility on 7/24/17 for open heart surgery. Open heart surgery was performed on 7/25/27 which included a sternotomy (mid chest) incision as well as incision sites for vein harvest in right leg. Patient #1's care plan did not have documentation addressing surgical incisions. According to nursing flow sheets, between admission and the nursing assessment of skin integrity on 7/28/17 Patient #1's skin was "WNL" (within normal limits). On 7/28/17 at 10:40 PM nursing flow sheet skin assessment noted "excoriated area on coccyx. Mepilex (cushioned foam dressing) applied". Patient #1's care plan for 7/28/17 and 7/29/17 had no documentation for newly identified skin impairment on coccyx, changing the dressing or care of area.

Patient #1's medical record lacked documentation on care plan for the newly found "excoriated area on coccyx", no skin integrity impairments for coccyx or surgical wound, no documentation on care plan showing the care and treatment delivered to Patient #1 showing progress toward the goal (healing of surgical incision) or documenting a change in patient condition (newly found excoriated area on coccyx). The lack of documentation of the above on Patient #1's care plan fails to meet the criteria as listed in facility policy above.

Patient #4's medical record was reviewed on 10/17/17 at 2:35 PM with Registered Nurse/Epic Trainer F who confirmed the following findings: Patient #4 was admitted to the facility on 8/7/17 with symptomatic atrial fibrillation (irregular heartbeat), an elevated heart rate and had a permanent pacemaker placed that requires incision on upper chest to place pacemaker. There is no documentation for monitoring incision on Patient #4's care plan.

Patient #4's medical record lacked documentation on care plan for surgical incision post pacemaker placement. The lack of documentation fails to meet the facility policy criteria for clinical documentation or skin and wound care.

Patient #9's medical record was reviewed on 10/17/17 at 4:35 PM with Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #9 was admitted to the facility on 7/24/17 with angina (chest pain) and heart failure and had a permanent pacemaker placed that requires incision on upper chest to place pacemaker. There is no documentation for monitoring incision on Patient #9's care plan.

Patient #9's medical record lacked documentation on care plan for surgical incision post pacemaker placement. The lack of documentation fails to meet policy criteria for clinical documentation or skin and wound care as listed above.

Patient #10's medical record was reviewed on 10/17/17 at 4:57 PM with Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #10 was admitted to the facility on 7/24/17 with third degree heart block (irregular heart rhythm) and had a permanent pacemaker placed that requires incision on upper chest to place pacemaker. There is no documentation for monitoring incision on Patient #10's care plan.

Patient #10's medical record lacked documentation on care plan for surgical incision post pacemaker placement. The lack of documention fails to meet policy criteria for clinical documentation or skin and wound care as listed above.

Per interview with Clinical Lead Registered Nurse G on 10/17/2017 at 11:38 AM, Nurse G stated that skin assessments are to be completed and documented every 8 hours in the flow sheet of the electronic medical record. If there is a wound or fragile skin at risk of becoming a wound/ulcer, the patient should have a care plan opened. If an ulcer develops during a patient's admission, a picture is taken of the area, there should be documentation on the flow sheets describing the area, a care plan should be opened and the wound nurse or provider should be consulted.





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Patient #12's closed medical record was reviewed on 10/17/2017 at 1:12 PM accompanied by Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #12, 94 years old, was admitted to the facility on 9/5/2017 with an ischemic (decreased blood supply cased by partial or total blockage of an artery) right foot and pneumonia. On 9/8/2017 at 6:11 AM a nurse documented that Patient #12 complained of tailbone pain and a mepilex dressing (cushioned foam type dressing) was applied. There is no update to the care plan to address this new problem or intervention. Per interview with Nurse K on 10/17/2017 at 1:40 PM, Nurse K stated, "Nope, I don't see one," when asked if a focus for Patient #12's skin integrity was present.

Patient #12's medical record lacked documentation on care plan for new skin integrity impairment or impairment on tailbone. The lack of documentation fails to meet the facility policy for clinical documentation or skin and wound care.

Patient #19's closed medical record was reviewed on 10/17/2017 at 4:05 PM accompanied by Clinical Informatics Registered Nurse K who confirmed the following findings: Patient #19 was admitted to the facility on 10/3/2017 with right lower leg ischemia. At 6:00 PM on 10/3/2017 the nursing flow sheet skin integrity section indicates that Patient #19 has a fully healed right groin incision from a surgery during a prior admission (cardiac catheterization on 9/14/2017). Per interview with Nurse K on 10/17/2017 at 4:20 PM, Nurse K stated that K did not see anything in the care plan regarding the new surgical incision.

Patient #19's medical record lacked documentation on care plan for surgical incision post endarterectomy and right groin. The lack of documentation fails to meet the facility policy for clinical documentation or skin and wound care.

Patient #20's closed medical record was reviewed on 10/17/2017 at 4:30 PM accompanied by Clinical Informatics Registered Nurse K and Clinical Informatics specialist F who confirmed the following findings: Patient #20 was admitted to the facility on 10/6/2017 with an unplanned opening of recent surgical incision from which Patient #20 had an amputation of the right leg below the knee. The incision opened up from a result of a fall and required surgical intervention. The nursing care plan includes a problem for risk for potential skin integrity and has the interventions for skin surveillance and pressure ulcer prevention however there is nothing on the care plan for the surgical wound or the ordered wound care that is 3 times per day. Per interview with Clinical Informatics specialist F on 10/17/2017 at 4:50 PM, F stated, "There should be something more pronounced in [Patient #20's] care plan because that is why [#20] was here."

Patient #20's medical record lacked documentation on care plan for surgical incision post amputation. The lack of documentation on care plan fails to meet the facility policy for clinical documentation or skin and wound care.

Based on record review and interview the facility failed to ensure high standards of medical practice and patient care. In 1 of 1 (Patient #1)surgical case reviewed surgical procedures that were unexpectedly ended out of a total of 9 surgical records reviewed.

The facility policy titled "INCAPACITATED SURGICAL TEAM MEMBER" dated 10/8/14 id #879 was reviewed on 10/17/17 at 11:00 AM. This document states under "PURPOSE: ASSURANCE OF PATIENT SAFETY", DEFINITION OF INCAPACITATED: An individual team member is unable to fulfill their unique role responsibilities during a surgical procedure." Under category "PROCEDURE: I. If any member of the surgical team becomes incapacitated, and unable to fulfill their responsibilities during a surgical procedure, the following steps will be taken to assure safe patient care: II. Incapacitated Surgeon: A. Call office/partner for replacement, if not available then; B. Call other offices of same specialty surgeons, if not available then; C. Notify Department Chairperson, if not available then; D. Notify Medical Staff President. E. Always notify the hospital Supervisor of the event. VI. In all of the above scenarios, scheduled cases may have delayed starts until staffing needs for cases in progress are met. VII. Complete a Safety Event Report with the even description, and document actions taken to remedy the event."

Patient #1's medical record was reviewed on 10/17/17 at 12:45 PM under "ADT Events" Patient #1 was admitted to "Ambulatory Cardiac Unit" on 7/24/17 at 10:21 AM, transferred out to "Perioperative" at 11:52 AM, remained in "Perioperative" until 2:13 PM and was then transferred out to Cardiac ICU (intensive care unit). Patient #1 remained in Cardiac ICU (intensive care unit) until transferred out 7/25/17 at 7:07 AM to "Perioperative" unit until 10:44 AM and transferred back to Cardiac ICU (intensive care unit). "Surgery Report" dated 7/24/27 12:57 AM under "Procedure" documents "vein dissected but left in leg" documented arrival time to operating room, "Patient prep complete 12:45 PM", "Procedure start (incision/injection/exam) 12:49 PM", "Procedure end 1:30 PM", "out of OR (operating room) 1:58" PM and "transfer to nursing unit ICU at 2:00 PM". "Surgery Report" also documents "Anesthesia start and end times of 11:52 AM and 2:11 PM. "Anesthesiology Assessment" was completed pre surgery by anesthesiologist on 7/24/17. Progress note completed in Ambulatory Cardiac Unit Registered Nurse P documents "Patient arrived to ACU (Ambulatory Cardiac Unit) for scheduled CABG (coronary artery by pass grafting/open heart surgery) with (Staff L). Consent signed. Patient ready for procedure and all questions were addressed. Pt transferred to OR (operating room) with cardiac team." Surgery Report documented "vein harvesting of right leg" completed while in operating room from 11:52 AM until 2:11 PM. Progress note dated 7/24/27 at 2:11 PM by Registered Nurse Staff Q in intensive care unit states "admitted to CICU (cardiac intensive care unit). Intubated. To be kept intubated and sedated overnight." Progress note by Registered Nurse Q dated 7/24/17 at 3:29 PM states "Admitted to CICU (cardiac intensive care unit) at 2:11 PM, intubated. OPCAB (open heart surgery) aborted during." Progress note by Registered Nurse Q on 7/25/17 in CICU (cardiac intensive care unit) states "(Staff L) updated at 4:00 AM-orders to hold Amiodarone and Lopressor (medications for heart). To surgery about 7:10 AM." Procedure note dated 7/25/17 at 7:00 AM documents procedure "BYPASS CARDIAC OFF PUMP X 4, take down of left internal mammary artery, insertion of temporary pacing wires x 2, ENDOSCOPIC VEIN HARVEST, GREATER SAPHENOUS". "Case tracking events" lists Patient #1 in OR (operating room) on 7/25/17 at 7:07 AM, Patient Prep Complete at 7:25 AM, Procedure Start (incision/injection/exam) at 7:31 AM, Procedure end at 11:19 AM, and anesthesia start time 7:07 AM end time 11:28 AM. Patient #1 transferred back to ICU (intensive care unit) at 11:26 AM.

There is no documentation as to why surgery was aborted on 7/24/17, the "Procedure" note dated 7/25/17 dictated by Physician L does not state reason for surgery being aborted on 7/24/17, no completed "Safety Event Report" with the event description and no documentation of contact to hospital management.

An interview was conducted with Clinical Informatics Registered Nurse K and Registered Nurse/Epic Trainer F on 10/17/17 at 12:45 PM during chart review of Patient #1. Staff F stated "I don't know why they would have taken (Patient #1) to surgery for 3 hours and then taken back to intensive care." Staff K on 10/17/17 at 4:45 PM reviewed chart for Patient #1 stated "it looks like surgery was canceled for some reason." When asked Staff K to provide physician documentation as to why surgery was canceled Staff K was unable to locate and stated "it would be the expectation that the physician would document any time that a surgery had to be canceled."