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Based on interviews and review of facility documentation it was determined the facility staff failed to ensure the patient was free from abuse and neglect of a patient (patient #4). The facility staff neglected to address patient #4's pain and comfort and a facility staff nurse spoke to patient #4 in manner which was perceived as being abusive.

The findings include:

A review of the clinical record revealed the patient #4 was admitted to the hospital for surgery on 9/21/2011. The surgery was uneventful and after surgery the patient had an extended stay in recovery and was transported to the 2nd floor surgical unit in the early evening on 9/22/2011.

The clinical record review indicates patient #4 had issues with pain in the abdomen and back with an intensity on the pain scale ranging from zero (0) to nine (9). The patient had orders for pain medications to include hydrocodone-acetaminophen 5/325 1-2 tabs(tablets) q (every) 6 hrs(hours) prn (as needed) for moderate pain. In addition, patient #4 had an order for Dilaudid IV injection 0.5 mg prn every 3 hrs for breakthrough pain or severe pain. The clinical record indicates on the evening of 9/22/2012 when patient #4 was a patient on the 2nd floor surgical unit she was assessed for pain at at 16:54 (4:54 pm) and her pain intensity was rated at a nine (9). At that time patient #4 was given two (2) tabs of hydrocodone. One hour later at 17:54 (5:54 pm) patient #4 was reassessed and pain was rated at a seven (7), no intervention was documented. At 18:30 (6:30 pm) patient #4's pain was rated at a seven (7), no intervention was documented. At 21:54 (9:54 pm) patient #4's pain was rated at a seven (7), patient #4 was given 2 tabs of hydrocodone. At 22:35 (10:35 pm) patient #4 was reported to be sleeping and at midnight the patient's pain was rated at a one (1), no intervention was documented. Patient #4's pain was rated at a seven (7) at 1:24 am and 2 tabs of hydrocodone was given.

The hospital policy titled "Pain Management Standards" reads in part: "patients have the right to have their pain managed, whether acute or chronic to the fullest extent possible." The policy further states "Pain Scales: Verbal or Visual Analogue Scale (VAS)/Numeric Scale-The scale allows the patient to self rate pain from a level "0" indicating no pain to a level of "10" which indicates the worst pain imaginable. 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain."

The clinical record revealed the facility staff failed to administer the prn Dilaudid during the patient #4's episode of pain unrelieved by hydrocodone and classified as severe based on the hospital's own policy.

A tour of the 2nd floor surgical unit was conducted at approximately 10 am on 3/22/2012. Employee #2 and #4 accompanied this writer on the tour. As part of the tour, the supply room was observed and the employees were asked if a patient needed special equipment such as an egg crate mattress or a special bed, what arrangements would be made? Employee # 2 responded they do not use egg crates due to infection control concerns and if a patient needed a special bed they have a contract with a local vendor. She further stated if an order was placed in the am, the bed would be delivered the same day.

A review of the grievance log was conducted on 3/22/2012 at approximately 11 am. The grievance log revealed the patient #4, had a family member file a grievance with the hospital related to the care received while a patient during the same admission under review by this agency. The grievance was filed beginning when patient #4 was still in the hospital on 9/23/2011 and a follow-up letter was sent after discharge.

The complainant in the grievance alleged the nurse on the 2nd floor surgical unit was verbally abusive to patient #4, called patient #4 fat, failed to furnish patient #4 a comfortable bed to sleep in when she was in pain and complained the bed was uncomfortable and patient #4 was forced to sleep in a chair. The complainant alleged the nurse told patient #4 to "get up" and failed to assist patient #4 to ambulate. The grievance log states in part: " nurse just would not help" "nurse tortured the patient, denied care and assistance, produced mental anguish and patient felt helpless". The back of the form listed predefined categories as concerns and action plan. Under the category of concerns the facility had filled in "lack of care in not providing the patient with another mattress." Under the category of action plan the facility had filled in "behavioral issues as to how nurse spoke with patient and names she directed to the patient" "address issue of another nurse giving family information which seemingly verified issues of abuse."

The grievance committee met on September 30, 2011 and a letter was sent to the complainant on October 7th, 2011 with their findings. The letter stated in part "conclusion-
-missed opportunity effective communication,
-expectation staff provide highest quality care
-apologize for any lack of timely response by supervisor
-reinforce staff call upon other departments
-improve customer service."

The letter also contained a section titled comments and analysis that stated: "we have recognized the opportunity to have had more effective communication regarding a change in the mattress for the comfort of (patient #4). The expectation of our staff is to consistently deliver the highest quality of care and we are sorry that your interaction with members of our staff did not convey."

An interview was conducted with employee # 2 while reviewing the grievance log. Employee #2 reports the nurse in question denied the allegations of calling the patient names and she further stated a breakdown of communication is the #1 problem with grievances.

An interview was conducted on 3/23/2012 with the unit manager of the 2nd floor. The manager recalled the patient in this complaint and the grievance (identified as patient #4) could not get up by herself and was a falls risk. She stated the hospital has a mobility team for assistance if needed or the staff may say I need to get some help but would not yell at a patient. She further stated that if family is present they may be utilized to assist with a patient if they are willing and able to help. A review of the personnel file was conducted during the interview which revealed the nurse in question received counseling on 12/31/11 for this episode with patient #4 on 9/22/2011 and she denied calling the patient names but did admit to telling patient #4 to "get up" and she stated her communication was inappropriate. The nurse was given a first and final warning and put on probation for three (3) months for violating the hospital's policy related to customer service.

An interview was conducted on 3/23/2012 at approximately 2 pm with two members of the grievance committee employee # 9 and #10. The employees clarified the section on the back on the grievance form for this surveyor. Employee #9 stated the "concerns and action plan" sections are derived from information in the complaint and the manager of the unit is to address those areas prior to meeting with the grievance committee, those are not "findings" of the grievance committee.

Based on observations, staff interview, sales representative interview and facility policy review the facility failed to prevent potential spread of infection(s) by permitting a sales representative to enter an operating room where a surgery was in progress without being appropriately dressed and without washing his hands. One patient (Patient #14) of 6 active patients in the survey sample was undergoing surgery when a sales representative was observed walking from the parking lot directly into surgery without washing his hands or changing his scrubs.

The Findings Include:

On 3/21/12 while standing at the elevators in the lobby with the Administrative Director of Operations (ADO) a person was observed walking through the parking lot into the lobby of the facility wearing scrubs, a surgical cap and a mask hung around their neck. The ADO was asked who the person was and she said she did not know. The person entered the lobby, walked through the dining room and proceeded down a hallway. The person went down another hallway through a set of doors that led directly into the surgical ante area. The person then crossed a taped redline on the floor and proceed to the end of the hallway that was lined with 5 surgical suites and into the fifth surgical suite. The person did not stop to wash their hands at any point.

The Director of Surgical Services (Employee #5) was present. The above observed events was described to the DSS and she stated, "You are kidding me? Lets see who that person is." The person was observed in the fifth surgical suite where Patient #14 was undergoing a repair of an abdominal hernia. The DSS stated, "He is a sales rep and he knows the rules. You do not enter surgery if you have been out of the surgical area in scrubs without changing."

The sales representative was interviewed and stated, "I was wrong. I should have changed my clothes. I am sorry. I will go change right now."

The facility policy titled "Operating Room Attire: Staff and Visitors" Review date of 3/11 was reviewed and stated the following:

1. All staff, visitors, and vendors are required to wear clean and proper attire when entering the semi- restricted, restricted areas, and PACU/Holding areas where invasive procedures are performed. Persons exiting the facility for any reason, including breaks, must change into street clothing to go outside, and change back into appropriate scrub clothing before reentering the semi-restricted, restricted and other treatment areas where invasive procedures are being performed. ...
9. Upon leaving the Surgical Service area
A....

2. When surgical staff including vendors and physicians, arrives to the facility in surgical scrub clothing, the person shall be required to change into scrub clothes supplied by the facility approved laundry service, before entering the semi-restricted, restricted and other treatment areas where invasive procedure are being performed.

Patient #14 was a 67 year old admitted on 3/21/12 with a diagnosis of Incisional Hernia and a history of rectal cancer, diabetes, hypertension, kidney disease, sepsis syndrome, status post necrotic, distal dead colon resolved with resection and history of vancomycin resistant Enterococcus, resolved.