HospitalInspections.org

30364


Based on record review and interview, the hospital failed to ensure in its resolution of a grievance the hospital provided the patient with a written notice of its decision that contained the steps taken on behalf of the patient to investigate the grievance, the result of the grievance process and the date of completion. This deficient practice is evidenced by issuing the same form letter involving the resolution of the grievances to 8 (#1, #3, #R1, #R2, #R3, #R4, #R5, #R6) of 8 patients reviewed for resolution of grievances.

Findings:

Review of a Grievance for Patient #1 dated 01/19/18 revealed she complained of a number of issues including being "pushed" out of a door by another patient during an activity, failing to receive an ordered medication, having her personal items inventoried in front of other people, and an unidentified MHT being rude to her.
Review of a letter dated 1/22/18 that had been sent sent to Patient #1 in response to her grievance filed on 1/19/18 revealed the following:
Patient #1, I wanted to follow up with you in response to our verbal conversation on Friday, January 19, 2018 in regards to the grievance letters obtained during your stay at our facility. Your complaints are being taken very seriously, and we have investigated the complaints.
At (named) Hospital we take all patient concerns very seriously and appreciate you sharing information about your stay with us. If I may ever be of assistance to you in the future, please feel free to contact me. My office number is (phone number listed).
The letter was signed by S3RN, Patient Advocate.


Review of a Grievance for Patient #3 dated 3/19/18 revealed she complained that S7MHT was rude to her. She said she had thrown up and S7MHT told her she needed to finish cleaning it up. She said she later tried to be nice to S7MHT with a good morning greeting but she was snubbed.
Review of a letter dated 4/3/18 that had been sent sent to Patient #3 in response to her grievance filed on 3/19/18 revealed the following:
Patient #3, I wanted to follow up with you in response to our verbal conversation on Tuesday, March 20, 2018 in regards to the grievance letter obtained during your stay at our facility. Your complaints are being taken very seriously, and we have investigated the complaints.
At (named) Hospital we take all patient concerns very seriously and appreciate you sharing information about your stay with us. If I may ever be of assistance to you in the future, please feel free to contact me. My office number is (phone number listed).
The letter was signed by S3RN, Patient Advocate.

Further review of the grievance binder revealed the response letter to separate grievances filed by Patients #R1, #R2, #R3, #R4, #R5 and #R6 was the same stock letter Patient #1 and #3 had received with different dates.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the physician's orders for 1 (#4) of 5 (#1-#5) patients sampled.

Findings:

Review of Patient #4's medical record revealed he had been admitted on 3/19/18 with the chief complaint of "Trying to control alcohol."

Review of Patient #4's Physician Order/Med Reconciliation that had been completed on 3/19/18 revealed the nurse had taken a telephone order to continue the patients home medications which included Cimetidine 200 mg by mouth every day, Fish Oil 1200 mg two by mouth every day and Iron 27 mg 1 by mouth every day. The medications were documented as having last been given on 3/19/18 which indicated the next doses should have been given on 3/20/18.

Review of Patient #4's MAR dated 3/20/18 revealed N/A had been written next to the Cimetidine, Fish Oil and Iron.

In an interview on 4/11/18 at 9:40 a.m. with S6LPN, she said she was passing the medications on Unit D on 3/20/18. She said she had written N/A on Patient #4's MAR because the Cimetidine, Iron and Fish Oil was not available for the patient. S6LPN said she may have called the family to bring the medications but they did not bring them until the afternoon. When asked why she did not give them in the afternoon, she said, "I do not know." When asked if she had notified the physician that the medications were not available, S6LPN said, "No." S6LPN said patients miss a day of some of their home medications about 3-4 times per month because the medications are unavailable.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications for 1 (#4) of 1 patients reviewed for medications withdrawn from the automated dispensing machine before being reviewed by a pharmacist.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of Patient #4's medical record reveled he had been admitted on 3/19/18 with the chief complaint of "Trying to control alcohol."

Review of Patient #4's MAR dated 3/19/18 revealed Librium 50 mg had been documented as having been administered at 7:01 p.m.

In an interview on 4/10/18 at 2:24 with S4Pharm, she said the pharmacy hours were 8:30 a.m. -4:30 p.m. Monday through Friday and on Saturday and Sunday from 2:00 p.m. until orders were done which was approximately 3 hours.

In an interview on 4/11/18 at 9:30 a.m. with S5RN, he said the nursing staff did not wait for the pharmacist to review first dose medications before they were administered if the pharmacist was not onsite.

In an interview on 4/11/18 at 9:40 a.m. with S6LPN, she said she had administered the Librium 50 mg to Patient #4 on 3/19/18 at 7:01 p.m. S6LPN verified it was a first dose and she did not call the pharmacist to review the medication before she administered the medication to Patient #4. S6LPN said if the pharmacist is not onsite the nurses do not call for review of first dose medications. S6LPN said the pharmacist would review the medication the next day when they arrived at the hospital.

In an interview on 4/11/18 at 10:30 a.m. with S4Pharm, she said as of now when a pharmacist is not at the hospital, the licensed nurse and the physician would review the first dose order of a medication for appropriateness. S4Pharm verified a pharmacist did not review first dose medications before the dose is administered after normal pharmacy hours unless someone called her but that was not the policy.