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Based on interview and medical record review, the hospital failed to ensure the P&P to address patients' complaints and grievances was implemented for five of six sampled patients whose grievances were reviewed (Patients 3, 29, 32, 33, and 34). This failure created an increased risk of a loss of patient's rights for hospital patients and the risk of persistent poor facility practices.

Findings:

The hospital's P&P titled Patient Complaints and Grievances dated 12/10, indicated in part "A patient grievance form will be made readily available to any patient wishing to file a grievance about Harbor-UCLA Medical Center. All grievances will be investigated and a written response generated to the grievance, if identifiable, within seven days of receipt of the grievance." and "..defines a 'patient grievance' as a formal or informal written or verbal complaint made to the hospital by a patient, or the patient's representative, regarding the patient's care .." and "A summary of fact-findings: include the names and titles of individuals involved in this part of the process. The resolution of the grievance: if grievance cannot be resolved, it should be identified as such, along with an explanation of why .."

1. During a review of Patient 33's medical record, the Patient Grievance Intake & Response Form dated 3/23/12 at 1216 hours, indicated Patient 33's family member made several allegations regarding the care the patient received including an appointment made in error, excessive wait time, and poor communication between providers and the patient, leading to confusion, concerns and possible delayed treatments.

During an interview with Patient Advocate 2 on 11/6/12 at 1140 hours, the Advocate stated she did not identify all of the allegations associated with the grievance of Patient 33. The Advocate stated she referred the complaint to the attending physician and follow-up was to occur. Documentation from the attending physician showed he had spoken with another department. The Advocate stated she believed Patient 33's care had been facilitated, but concurred there was no documentation all of the concerns in the complaint had been addressed. The Advocate stated they were short-staffed and lacked the resources to address all of the allegations.

In an interview with Patient Safety Officer 2 on 11/6/12 at 1140 hours, she stated the allegations made by Patient 33's family member might have been addressed, but were not documented.

2. During a review of Patient 29's medical record, the Patient Grievance Intake and Response Form dated 3/29/12 at 1213 hours, documented allegations regarding the physician's behavior including an allegation of possibly abusive behavior by one physician.

Patient 29's grievance was reviewed on 11/6/12, with Patient Advocate 2 and Patient Safety Officer 2. The investigation included a written response from a junior physician present during the incident who denied the senior physician present behaved inappropriately, but there were no interviews conducted to the nursing staff.

In an interview with Patient Safety Officer 2 and Patient Advocate 2 on 11/6/12 at 1330 hours, Patient Safety Officer 2 stated a statement should have been obtained from the nurse practitioner in the clinic. The Advocate stated complaints regarding physicians were reviewed in the Grievance Committee.

Patient Safety Officer 2 was asked if Patient 29's complaint regarding the physician's behavior was reviewed in the Grievance Committee. Patient Safety Officer 2 reviewed the Grievance Committee minutes and stated, in error, it had not been reviewed.

3. During a review of Patient 32's medical record on 11/6/12 at 1100 hours, the medical record indicated Patient 32 came to the office of the Patient Advocate to complain she was contacted by telephone to come for an appointment in the OB/GYN clinic; however, when she arrived she was told she did not have an appointment. The Patient Advocate's office file contained a form with basic information about the patient's complaint; however, no grievance form was completed by the patient.

In an interview with Patient Advocate 1 on 11/6/12 at 1100 hours, the Advocate stated she was new to her position at the time of Patient 32's complaint. The Advocate stated she did not document the events related to the complaint. The Advocate stated she believed the OB/GYN department was called and she was told the patient did not have an appointment, but she did not document the statements of the person in the department to whom she spoke. The Advocate stated she did not have time to review the patient's record to see if an appointment had been made. The Advocate believed she had offered the patient a grievance form to complete, but this was not documented. The Advocate stated since the patient did not complete the grievance form, her complaint was not seen as a grievance. The Advocate stated she completed the Patient Grievance Intake and Response Form on all patients referred to her, even if they only wanted directions to a clinic.

4. During a review of Patient 34's medical record, the Patient Grievance Intake & Response Form dated 3/21/12 at 1506 hours, indicated Patient 34 submitted a grievance regarding the quality of care she received. The patient stated "she has been coming to the doctor over 14 months for pain and is only given pain medication. No one has found the source of the pain." There was no documentation in the patient's file to show an investigation of the patient's complaint.

During an interview with Patient Advocate 2 on 11/6/12 at 1330 hours, the Advocate confirmed no investigation was conducted for Patient 34.


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5. On 10/10/12, during a telephone interview, Patient 3 stated she went to the hospital's ED on 9/30/12, for a possible foreign object in her throat. After diagnostic tests, the patient was told by ED staff a specialist would consult. A procedure might be required to remove the foreign object and she would be given medications for relaxation. Patient 3 stated she waited in the ED for hours and then a nurse came to discharge her. Patient 3 stated she felt upset because no one explained to her what happened to the foreign object in her throat. Patient 3 stated she made a complaint to the charge nurse but was not satisfied with the response. The patient stated she was given the telephone number of the Department of Public Health to call to make a complaint.

On 11/5/12 at 0950 hours, the hospital's ED was toured with the ED Manager and RN H. RN H stated when ED staff received a patient's complaint they tried to solve the complaint immediately. If the complaint could not be resolved, then the staff reported the patient's concern to the shift charge nurse. The charge nurse tried to solve the complaint, but if unsuccessful, the charge person would report the concern to RN H. The complaint was reported up to the hospital management level if the complaint was unable to be resolved. RN H stated if the complaint was resolved by the primary ED staff, there was no need for documentation. If the complaint was handled on another level, the allegation was documented in the hospital's log and the hospital's Risk Management initiated an investigation.

Patient 3's medical record was reviewed on 11/7/12. Patient 3 went to the hospital's ED on 9/30/12 at 1859 hours. The admitting diagnosis was documented "foreign body." The Emergency Nursing Triage/Assessment Flowsheet dated 10/1/12 at 0330 hours, showed documentation at the time of discharge Patient 3 stated she had been told by a physician she had something stuck in her throat and she wanted a doctor to remove it.

Documentation also showed at 0335 hours, MD 3 was at the bedside to clarify the patient's test results and answered questions. At 0345 hours, documentation showed the patient was not happy about the explanation from MD 3. The patient requested to file a formal complaint. The patient was sent to the charge nurse's office. At 0355 hours, the ED charge nurse spoke with the patient.
On 11/5/12 at 1600 hours, Assistant Hospital Administrator 1 reviewed the hospital's complaint log. The log showed Patient 3's complaint was entered into the log by the ED staff; however, there was no further documentation to show an investigation was initiated for the complaint.

Based on interview and medical record review, the hospital failed to ensure a written response was generated to address the grievances of three of five sampled patients' grievances reviewed (Patients 32, 33 and 34). The lack of a written response created the risk of unresolved patient grievances for hospital patients.

Findings:

The hospital's P&P 343 titled Patient Complaints and Grievances revised 12/10, read in part, "All grievances will be investigated and a written response generated to the grievant, if identifiable, within seven days of receipt of the grievance."

1. During a review of Patient 33's medical record, the Patient Grievance Intake & Response Form dated 3/23/12, indicated Patient 33's family member made several allegations regarding the care her father received including an appointment made in error, excessive wait time, and poor communication between providers and the patient, leading to confusion, concerns and possible delayed treatments.

During an interview with Patient Advocate 2 on 11/6/12 at 1140 hours, the Advocate stated no written acknowledgement or response letter was sent to address Patient 33's complaint. The Advocate stated she believed a verbal response was provided.

2. During a review of Patient 32's medical record on 11/6/12, the medical record indicated Patient 32 came to the office of the Patient Advocate on 4/17/12, to complain she was contacted by telephone to come for an appointment in the OB/GYN clinic, but when she arrived was she told she did not have an appointment. The Patient Advocate office file contained a form with basic information about the complaint, but there was no completed grievance form and no written response.

During an interview with Patient Advocate 1, the Advocate stated since the patient did not fill out the grievance form, it was not really considered a grievance, and no response was mailed to the patient.

3. During a review of Patient 34's medical record on 11/6/12, the medical record indicated Patient 34 reported a complaint alleging poor medical treatment of persistent back pain over the course of 14 months on 3/21/12. The patient's complaint was recorded on the facility form, Patient Grievance Intake and Response Form; but there was no evidence of a written response in the file.

During an interview with Patient Advocate 2 on 11/6/12 at 1330 hours, the Advocate confirmed she did not provide a written response to the patient.

During an interview with Patient Safety Officer 2 on 11/6/12 at 1055 hours, she stated if a patient was okay with the grievance being handled over the phone, no written response was required.

Based on interview and medical record review, the hospital failed to protect the patient's right to provide an advance directive during their treatment at the hospital for two of 39 sampled patients (Patients 14 and 15). This failure increased the risk of loss of patient rights for hospital patients.

Findings:

The hospital's P&P titled Advance Directives dated 3/99, indicated "Registration Staff will ask all adult patients who are able to give consent at the time of admission if they have an Advance Directive."

1. Patient 14's medical record was reviewed on 11/5/12. The Conditions of Admission/Clinic Visit form dated 5/9/12 at 0810 hours, showed the advance directive section of the pre-printed form contained check boxes to indicate whether or not the patient had an advance directive, but none was marked.

2. Patient 15's medical record was reviewed on 11/5/12. The General Consent form dated 11/5/12 at 0730 hours, showed the Advance Directive section of the pre-printed form contained check boxes to indicate whether or not the patient had an advance directive, but none was marked.

During an interview with RN G on 11/5/12 at 1115 hours, the RN confirmed the advance directive sections for these two patients had been left blank and they should have been completed by the Registration staff with the patient.

Based on observation, the size of the OSSA seating area for same day outpatient surgery patients did not allow adequate access to the patients in case of emergency and provided no direct visibility to recovering patients.

Findings:

On 11/6/12 at 0930 hours, the OSSA seating area in the corner of the room between Beds 3 and 4 was inspected with ADON 1.

The corner area contained four lounge chairs used for patients waiting for outpatient surgery as well as patients waiting for discharge after the surgery. The area measured 12 X 6 ft in size. Each lounge chair, when in the reclined position, measured 5 and 1/2 ft long. When all chairs were reclined, the area provided no space for access to the patients in the chairs against the wall in case of emergency. In addition, the corner area provided no direct visibility of recovering patients when the curtains of Beds 3 and 4 were closed.

Based on observation, interview and medical record review, the hospital failed to ensure the medical records of two of 39 sampled patients (Patient 26 and 27) were secured and not open to being viewed by any visitors or staff not involved in patient care.

Findings:

On 11/6/12 at 1050 hours, the Interventional Radiology Department was toured. An anesthesia cart was observed parked in the hallway with staff walking past. An anesthesia technician was cleaning the cart. During an inspection of the cart, medical records for two different patients were found stored in the bottom drawer of the anesthesia cart including two pages of the anesthesiology notes and a copy of the anesthesia record belonged to Patient 26 and two pages of anesthesia notes belonged to Patient 27.

When interviewed, the anesthesia technician stated the cart could not be locked and was left without staff attendance. The technician was unable to state how long the patients' medical record had been in the cart.

On 11/7/12 at 1405 hours, MD 4 was interviewed. MD 4 stated one of the resident physicians had left the medical records of Patients 26 and 27 in the cart by accident.

Based on interview and record review, the hospital's QA program failed to evaluate the PSN, death review, and grievance processes to ascertain if these programs functioned as they were designed; to monitor, collect, process and respond to information about patient care. The hospital's QA program failed to validate the data from the grievance processes. Two of three PSN incidents reviewed (Patients 31 and 40), one of two deaths reviewed (Patient 31), and four of five grievances reviewed (Patients 29, 32, 33 and 34), did not show an investigation was conducted with an analysis and a written response to the incidents and grievances according to the hospital's P&P. In addition, the data produced to categorize grievances was not subject to validation to ensure it accurately reflected the grievances presented. These failures created the risk of persistent poor healthcare practices and poor healthcare outcomes for patients using the facility.

Findings:

1. The hospital's Quality of Care Plan (2012-2013), read in part, "The purpose of this plan is to define and describe the plan framework, assure the organization designs new processes well and systematically communicates, monitors, analyzes and improves the existing processes in order to provide high quality care and services in a safe environment." "Clinical Data Monitoring Panel Specific duties include, but are not limited to: Assure important clinical processes are measured, assessed, and improved..."

The hospital's P&P titled Event Notification Reports dated 3/99, indicated "Events are entered directly into the PSN system and will be followed up by appropriate management/risk management and quality improvement processes."

The hospital's P&P titled Critical- Clinical Event (Including Sentinel Event) Reporting and Follow-Up dated 3/1/99, page one of five, indicated "Risk Management will coordinate an investigation of the source of critical clinical events and initiate any mitigation actions that may be indicated." Page three of five, indicated "Intensive Assessment: 1. The intensive assessment shall reveal a comprehensive clinical and administrative review of the event has occurred."

a. The medical record for Patient 31 was selected for review on 11/6/12, from a list of PSN reports from March, 2012, and from a list of patient code blues (needing emergency resuscitation) from March, 2012. Patient 31 required and received CPR while on an inpatient medical surgical floor, the day after admission to treat cellulitis (a bacterial infection of the soft tissues), and subsequently died in the hospital. Cross Reference to A286 #1.

During an interview with RM Staff on 11/7/12 at 0830, the medical record and risk management records for Patient 31 were reviewed. The RM Staff was unable to locate documentation to show an investigation of the PSN report generated by Patient 31's fatality had occurred.

During an interview with the QA RN on 11/7/12 at 0910 hours, the medical record for Patient 31 and the associated PSN records were reviewed. The QA RN was unable to locate documented evidence to show an investigation into the antecedent events that led up to the need for CPR for Patient 31. There was no documented evidence to show an investigation into the PSN report generated by Patient 31's code blue, transfer to the ICU, and fatality had occurred.

b. An incident regarding Patient 40 was reported on the PSN on 3/26/12, due to a canceled surgery. The incident was reviewed with RM Staff on 11/7/12 at 1055 hours. The RM Staff stated the nurse manager of the department reviewed the PSN and referred it to the vascular surgery department. The RM Staff stated there were no details documented of the nurse manager's investigation. The RM Staff stated it was not clear as to why the incident was referred to the vascular surgery department or what that department had done with the incident.

The RM Staff stated each event reported in the PSN was expected to be reviewed by risk management or other staff. The nurse manager of the appropriate unit was also notified and reviewed the event. The RM Staff stated the staff was trained on how to perform the reviews at the onset of their employment. The RM Staff stated there was no additional oversight of the PSN, such as sampling of reported incidents, to ensure follow-up of reported events was occurring.

2. The hospital's P&P titled Patient Complaints and Grievances dated 12/10, indicated in part "A patient grievance form will be made readily available to any patient wishing to file a grievance about Harbor-UCLA Medical Center. All grievances will be investigated and a written response generated to the grievant, if identifiable, within seven days of receipt of the grievance." and "...defines a 'patient grievance' as a formal or informal written or verbal complaint is made to the hospital by a patient, or the patient's representative, regarding the patient's care ..." and "A summary of fact-findings: include the names and titles of individuals involved in this part of the process. The resolution of the grievance: if grievance cannot be resolved, it should be identified as such, along with an explanation of why... "

During a review of the medical records for Patients 29, 32, 33, and 34, the Patient Grievance Intake & Response Forms showed the following elements were missing: the investigation of the allegations, the analysis, the written response and the forwarding of the grievance for review by other committees. Cross Reference to A119 and A123.

During an interview with Patient Advocate 2 on 11/6/12 at 1140 hours, the Advocate stated they tried to facilitate care for the patients who had filed grievances, but they were short-staffed and lacked the resources necessary to address all of the allegations in the grievances.

Patient Advocate 2 also stated there was no QA oversight of the grievance process unless it was a physician or quality of care related complaint and there was no oversight to ensure the response letter to the grievance was generated.

In an interview with the Director of QA on 11/6/12 at 1450 hours, she stated only physician related grievances were referred to quality assurance for oversight.

3. Data regarding grievances dated July through September, 2012, was reviewed beginning on 11/6/12. The data showed grievances were graphed by category as well as by location or department. Thirty six categories of complaints were included on the graph including "communication," quality of care," "appointment," "wait," and 32 other categories. Departments represented in the graph included "oncology," "head and neck," and 42 other departments.

a. The grievance made by Patient 33's family member was reviewed on 11/6/12. The grievance contained multiple allegations involving the patient's care in the oncology, radiation oncology and head and neck clinics. The allegations included an appointment made in error, excessive wait time, poor communication between providers, and poor communication with the patient, leading to confusion, concerns and possible delayed treatments.

During an interview with Patient Advocate 2 on 11/6/12 at 1140 hours, the Advocate stated the allegations regarding Patient 33's care were not separately identified. The Advocate stated she thought the grievance was assigned to the data category "communication" because the chief issue was felt to be communication problems. The Advocate stated there was no process to validate if data was gathered on grievances.

Patient Safety Officer 2 was interviewed on 11/6/12 at 1110 hours. The Patient Safety Officer stated she aggregated data regarding grievances by assigning each complainant's grievance to a single category. The data was presented to the grievance committee. The Patient Safety Officer stated she thought the Chief Quality Officer reported the data to others.

Based on observation and interview, the hospital failed to ensure all clinical staff including temporary clinical staff such as medical students and visiting RMS were fully included in the training and assessment programs conducted by the hospital, creating the increased risk of substandard healthcare for patients in the hospital.

Findings:

1. During an observation on 11/5/12 at 1030 hours, in the surgical subspecialty clinic, an RMS was observed to take off her gloves while leaving a patient room. The RMS was not observed to wash her hands or use a hand sanitizer after removing her gloves. The RMS proceeded to two additional patient rooms without an observation of hand washing or use of an alcohol based hand sanitizer.

During an interview with the Chief Quality Officer on 11/7/12 at 0913 hours, she was asked how the hospital included the RMS in their quality assurance program. The Chief Quality Officer stated the new staff orientation was now three days long. When asked how RMS who are visiting from outside hospitals were included in the QA process, the Chief Quality Officer stated the Essentials of Patient Safety, a 12-page orientation covering medical errors, hand hygiene, etc. was given to them. The Chief Quality Officer stated the hospital is working on giving visiting RMS the safety module provided to facility RMS.

During an interview with the Patient Safety Officer on 11/7/12 at 1000 hours, he stated resident physicians were given an orientation training module, but the hospital had not assessed the impact of the orientation module on resident physician behavior and standards. The Patient Safety Officer stated the hospital had a hand hygiene improvement program which was focused on increasing hand hygiene for all hospital staff. When asked if the hand hygiene improvement program included RMS and medical students, he stated "not medical students."

During an interview with the Director Infection Control on 11/7/12 at 1005 hours, he stated all employees signed an attestation form indicating they received the hand hygiene education, but he was not sure if there was a process for including RMS and medical students.

When questioned about an evaluation of the hand hygiene performance improvement project for RSM, the Patient Safety Officer stated they "have not evaluated the impact" of the program. He stated they "focused on repeating the information." When asked if there were any future plans to assess the efficacy of the hand hygiene performance improvement project, the Patient Safety Officer stated "no."

Based on interview and record review, the hospital failed to ensure the scope of the quality assurance program included measuring and analyzing adverse events such as incidents reported in the PSN, unexpected code blues and grievances for Patients 29, 31, 32, 33, 34 and 40, creating the risk of persistent poor healthcare practices and poor healthcare outcomes for patients using the facility.

Findings:

1. The hospital's P&P titled Department Quality Improvement and Risk Management Outcome Indicators showed adverse events were to be reported to PSN including "Unexpected transfer from general care to a special care unit" and "Death within 30 days following surgery."

The hospital's P&P titled Event Notification Reports dated 3/99, indicated "Events are entered directly into the PSN system and will be followed up by appropriate management/risk management and quality improvement processes."

The hospital's P&P titled Critical-Clinical Event (Including Sentinel Event) Reporting and Follow-Up" dated 3/1/99, page 1 of 5, indicated "Risk Management will coordinate an investigation of the source of critical clinical events and initiate any mitigation actions that may be indicated" and page 3 of 5, indicated "Intensive Assessment 1. The intensive assessment shall reveal a comprehensive clinical and administrative review of the event has occurred."

During an interview with the RM Staff on 11/6/12 at 1055 hours, she stated each event reported in the PSN was expected to be reviewed by risk management or other staff. The nurse manager of the appropriate unit was also notified and reviewed the event. The RM Staff stated the staff was trained on how to perform the reviews at the onset of their employment.

On 11/6/12, the hospital PSN incident log for March, 2012, was reviewed. Three incidents for Patients 31 and 40 were selected for review.

a. Patient 31's medical record review showed the patient was subject to review according to the hospital's criteria because the patient experienced a code blue while not in the ICU.

During a review of the medical record for Patient 31, the CPR record dated 3/28/12 at 2140 hours, indicated Patient 31 required and received CPR while on an inpatient medical surgical unit, the day after admission for cellulitis. Patient 31 was subsequently transferred to the ICU and diagnosed with a more serious condition, Necrotizing Fasciitis (a frequently fatal bacterial infection of the soft tissues). Despite a surgical treatment, the patient succumbed to his illness three days after admission.

During an interview with the RM Staff on 11/7/12 at 0830 hours, she reviewed Patient 31's medical record and risk management records. The RM Staff was unable to find documentation an investigation of the PSN report generated by Patient 31's fatality had occurred.

During an interview with the QA RN on 11/7/12 at 0910 hours, she reviewed Patient 31's medical record and associated PSN records. The QA RN stated a nurse reviewing the case should have noticed Patient 31's heart rate had been increasing prior to the need for CPR. The QA RN was unable to find documented evidence to show events that had occurred prior to Patient 31's code blue and transfer to the ICU were investigated.

b. An incident for Patient 40 was reported on the PSN on 3/26/12, due to a canceled surgery.

The PSN report was reviewed with the RM Staff on 11/7/12 at 1055 hours. The RM Staff stated the nurse manager of the department reviewed the PSN and referred it to the vascular surgery department. The RM Staff stated no details of the nurse manager's investigation were documented. It was not clear as to why the incident was referred to the vascular surgery department or what that department had done with the incident.

2. The hospital's P&P titled Patient Complaints and Grievances dated 12/10, indicated in part "A patient grievance form will be made readily available to any patient wishing to file a grievance about Harbor-UCLA Medical Center. All grievances will be investigated and a written response generated to the grievant, if identifiable, within seven days of receipt of the grievance." and "..defines a 'patient grievance' as a formal or informal written or verbal complaint made to the hospital by a patient, or the patient's representative, regarding the patient's care ..," and "A summary of fact-findings: include the names and titles of individuals involved in this part of the process. The resolution of the grievance: if grievance cannot be resolved, it should be identified as such, along with an explanation of why ..."

During a review of grievances dated March and April, 2012, four of the five patient grievances reviewed (Patients 29, 32, 33 and 34) did not show the grievance allegations were identified, investigated, analyzed and reported.

a. During a review of Patient 33's medical record, the Patient Grievance Intake & Response Form, dated 3/23/12 at 1216 hours, indicated Patient 33's family member made several allegations regarding the care the patient received including an appointment made in error, excessive wait time, and poor communication between providers and the patient, leading to confusion, concerns and possible delayed treatments.

During an interview with Patient Advocate 2 on 11/6/12 at 1140 hours, the Advocate stated she did not identify all of the allegations associated with the grievance of Patient 33. The Advocate stated she referred the complaint to the attending physician and follow-up was to occur. Documentation from the attending physician showed he had spoken with another department. The Advocate stated she believed Patient 33's care had been facilitated, but concurred there was no documentation all of the concerns in the complaint had been addressed. The Advocate stated they were short-staffed and lacked the resources to address all of the allegations.

In an interview with Patient Safety Officer 2 on 11/6/12 at 1140 hours, she stated the allegations made by Patient 33's family member might have been addressed, but were not documented.

b. During a review of Patient 29's medical record, the Patient Grievance Intake and Response Form dated 3/29/12 at 1213 hours, documented allegations regarding the physician's behavior including an allegation of possibly abusive behavior by one physician.

Patient 29's grievance was reviewed on 11/6/12, with Patient Advocate 2 and Patient Safety Officer 2. The investigation included a written response from a junior physician present during the incident who denied the senior physician present behaved inappropriately, but there were no interviews conducted to the nursing staff.

In an interview with Patient Safety Officer 2 and Patient Advocate 2 on 11/6/12 at 1330 hours, Patient Safety Officer 2 stated a statement should have been obtained from the nurse practitioner in the clinic. The Advocate stated complaints regarding physicians were reviewed in the Grievance Committee.

Patient Safety Officer 2 was asked if Patient 29's complaint regarding the physician's behavior was reviewed in the Grievance Committee. Admin 2 reviewed the Grievance Committee minutes and stated it had not been reviewed in error.

c. During a review of Patient 32's medical record, the medical record showed Patient 32 complained she was contacted by telephone to come for an appointment in the Ob-gyn clinic; but when she arrived was told she did not have an appointment. On 11/6/12 at 1100 hours, Patient Advocate 1 stated events related to the complaint were not documented. The Advocate stated since the patient did not complete the grievance form, her complaint was not seen as a grievance. Patient 32 was advised to discuss her concerns with a physician during a future visit.

d. During a review of Patient 34's medical record, the Patient Grievance Intake & Response Form dated 3/21/12 at 1506 hours, indicated Patient 34 submitted a grievance regarding the quality of care she received. The patient stated "she has been coming to the Doctor over 14 months for pain and is only given pain medication. No one has found the source of the pain.." There was no documentation in the patient's file to show an investigation of the patient's complaint.

During an interview with Patient Advocate 2 on 11/6/12 at 1330 hours, the Advocate confirmed no investigation was conducted for Patient 34.

During an interview with Patient Safety Officer 2 on 11/6/12 at 1110 hours, she stated the data gathered during the grievance process used to be presented to the CEO; however, the data was now presented to the grievance committee. Patient Safety Officer 2 stated she thought the Director of QA presented grievance data and information to the quality department.

In an interview with the Director of QA on 11/6/12, she stated only information from grievances regarding physician quality of care issues was presented to the performance panel.

Based on observation, interview and record review, the hospital failed to ensure nursing staff implemented the P&P addressing Pressure Ulcer Prevention and Management for three of seven sampled patients reviewed with pressure ulcers (Patients 2, 10 and 12) and followed the WCN's recommendations to avoid positioning the patients directly on a pressure ulcer. In addition, nursing documentation did not show existing pressure ulcers were documented at the correct anatomical site; high risk patients and patients with pressure ulcers were repositioned at least every two hours to avoid direct pressure at the site of breakdown; and new pressure ulcers were photographed at the time of discovery and/or at the time of admission. This resulted in Patient 2 developing skin breakdown, Patient 12's existing pressure ulcer worsened and there was no improvement in Patient 10's pressure ulcers.

Findings:

In February 2007, the NPUAP defined a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

The EPUAP/NPUAP guidelines for the prevention of pressure ulcers showed "Reposition frequency will be determined by the individual's tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessment of individual's skin condition." Guidelines developed by the EPUAP/NPUAP for treatment of pressure ulcers showed "The schedule for repositioning the patient should be based on the degree to which the individual is at risk for developing pressure ulcers and on the response of the tissue to pressure. Thus, the higher the risk for additional pressure ulcer the more frequently the patient should be repositioned." The guidelines also showed "establishing turning frequency based on the characteristic of support surface and the individual's response and "written repositioning schedules should be developed even when patients are using a pressure-reducing support surface."

The hospital's P&P titled Pressure Ulcer Prevention and Management dated 8/18/10, was reviewed on 11/5/12. The stated purpose of the P&P was to ensure initial and ongoing assessments and interventions to maintain or restore skin integrity, prevent skin breakdown and promote healing using the most current and evidenced based clinical guidelines.

Components of a complete assessment include physical inspection and when indicated completion of the Braden Scale. The Braden Scale is the most commonly used pressure ulcer assessment tool in the United States. It consists of six subscales based on the primary etiologic factors of pressure ulcer development. The lower the score, the higher the patient's risk for developing a pressure ulcer. All patients' skin integrity must be inspected and documented on admission/transfer and every shift. When changes/variances are noted, these changes must be described and documented in the nursing notes.

Pressure ulcer assessment and documentation of each site includes: location; size in cm (length x width x depth); staging (depth of tissue destruction); color; odor; condition of surrounding skin; and photographic documentation. If a pressure ulcer is present upon admission or when a pressure ulcer is identified, the patient's assigned or accountable RN must assess and photograph each site and document in the medical record.

Components of preventive measures implemented include the frequency of turning and repositioning (a minimum of every two hours) and skin/pressure ulcer assessment according to established criteria documented on the Nursing Flowsheet.

Routine prevention measures for patients at risk for pressure ulcer development (Braden Scale of 13-16) includes minimizing pressure by encouraging patients to reposition frequently (minimally every two hours). Avoid positioning patients directly on pressure ulcer sites.

1. Patient 12 was observed on 11/5/12 at 1430 hours, during a tour of the 6W unit accompanied by the Education Coordinator and the 6W Nurse Manager. The patient was lying in bed and positioned on her back. The patient appeared alert and oriented, and when asked, stated she repositioned herself in the bed. The patient stated she had never been told not to lie on her back.

Patient 12's medical record review showed she was admitted to the hospital on 10/26/12, via the ED at 0533 hours. The admission nursing assessment documented the patient had a Stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) and a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed which may also present as an intact or open/ruptured fluid-filled blister) pressure ulcers present at the time of transfer from the ED. The body diagram on the admission form showed the Stage I pressure ulcer was located at the sacrococcyx (tailbone) area. The Stage II pressure ulcer was located above the sacrum (area above the tailbone), slightly to the right of midline. There were no photographs taken of the pressure ulcers found in the medical record on admission.

However, review of the Skin Care Team Wound Documentation dated 10/26/12 at 0900 hours, showed three pressure ulcers were found and assessed after a complete body check of Patient 12 was completed. Site #1 was a Stage II pressure ulcer on the lumbar area measuring 1.2 cm x 1.2 cm x 0.1 cm in size. Site #2 was a Stage I pressure ulcer measuring 7 cm x 8 cm in size on the sacrococcygeal. Site #3 was an Unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dying/dead tissue) and/or eschar (dead tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) to the right heel measuring 2.5 cm x 3 cm in size. Photographs of the three wounds were taken at that time by the WCN.

The WCN's recommendations included to turn the patient side to side only for now and to offload the heels from the mattress.

Review of Patient 12's Nursing Flowsheets showed a boxed area on the Ongoing Physical Assessment page for the documentation of pressure ulcers. There were boxes to check to show the stage of the pressure ulcer and an area to document location. At the bottom of the page was a body diagram picture to mark the location of wounds and pressure ulcers.

Review of Patient 12's flowsheet dated 10/27 to 11/4/12, showed the pressure ulcers were documented as "sacral/coccyx" and "right heel." The check box to show the stage of the "sacral/coccyx" pressure ulcer was left blank on each shift assessment. There was no documentation to show the presence of a lumbar Stage II pressure ulcer. The body diagram picture was not completed.

Review of the flowsheets for Patient 12 dated 10/27 to 11/4/12, showed the patient was consistently turned every two hours; however the patient was alternately positioned left, right and supine (back) where the pressure ulcers were located.

Review of the Skin Care Team Wound Documentation dated 11/5/12 at 0920 hours, showed Site #1, the Stage II pressure ulcer to the lumbar area and Site #3, the Unstageable pressure ulcer to the right heel were somewhat smaller in size; however, the pressure ulcer to the sacrococcyx had increased from a Stage I to a Stage II pressure ulcer measuring 5 cm x 3.5 cm x 0.1 cm in size.

When interviewed, the Education Coordinator confirmed nursing had not documented shift assessments on the Nursing Flowsheets for Patient 12 to show the stage and the presence of the two separate pressure ulcers on the patient's lumbar and on the sacrococcyx. The Education Coordinator stated, ideally the patient's pressure ulcers should have been photographed by the ED RN before transfer to the nursing unit at the time of admission, but the photographs were not taken until the WCN saw the patient several hours later. The Education Coordinator stated the floor nurses had to obtain a camera from the nursing office. The WCN had a digital camera which downloaded the photographs into the electronic medical record.

2. Patient 2 was observed during a tour of 3E accompanied by the Education Coordinator and RN A on 11/5/12 at 0945 hours. Patient 2 was positioned slightly to the right with a pillow wedged behind his left upper back to hold him in place. RN A stated she assessed a new Stage I pressure ulcer on the patient's left upper back at the beginning of her shift that morning. RN A stated the WCN had just finished her evaluation of the wound.

When the RN was asked to turn Patient 2 to allow observation of the pressure ulcer, the RN was required to turn the patient more to the right side. The site of the pressure ulcer over a bony area was observed in direct contact with the pillow used as a positioning wedge.

A family member at Patient 2's bedside stated the pressure ulcer was assessed by the nurse on the previous night shift. The family member stated she observed the nurse cleaning the skin at the site. When asked if nursing assisted the patient to turn every two hours, the family member stated she was constantly at the bedside and the patient was turned only about two to three times a shift during his stay on the telemetry unit, although the family member stated on this unit he was turned more frequently.

Patient 2's medical record review showed an admission date of 10/24/12. The patient's Braden Score was not assessed as high risk at the time of admission as the patient was alert, oriented and able to move around in bed unassisted. However, by 10/29/12, after a change of condition, the patient was transferred to the ICU. The Braden Score was assessed as low as 9 (high risk) as the patient was confined to bed and required moderate to maximum assistance in moving.

The Braden Score for Patient 2 continued to be assessed as high risk on 11/2/12, after transfer from the ICU to a telemetry unit on the evening shift of 11/1/12. Review of the Nursing Flow Sheet dated 11/1/12, did not show documentation the patient's skin was assessed at the time of transfer at 1715 hours. Review of the nursing notes showed the patient was alert to name only at that time. Review of the area to document turning showed the patient was positioned supine at 1700 hours. There was no documentation to show the patient was repositioned during the remainder of the evening shift.

Review of the Nursing Flow Sheet dated 11/2/12, showed Patient 2 remained in the supine position from 0600 until 1200 hours. Documentation showed the patient was again positioned supine at 1400 and 1600 hours. There was no documentation to show the patient was repositioned every two hours from 1600 hours through 2300 hours.

Review of the Nursing Flow Sheet dated 11/3/12, showed Patient 2 "self" turned on the night and day shifts, and on the evening shift, documentation showed the patient was assisted to turn every two hours; however, there was no documentation of the position of the patient when turned for all three shifts.

Patient 2 was transferred to 3E on the night shift 11/4/12. The patient's skin was assessed as intact at the time of transfer. Documentation showed the patient was turned side to side and back every two hours.

Review of the Nursing Flow Sheet dated 11/5/12, for the night shift, did not show documentation of the skin breakdown as observed by Patient 2's family member. The Stage I pressure ulcer on the left upper back was documented by RN A for the first time at 0800 hours on 11/5/12.

When interviewed, RN A stated the night shift RN did not inform her that a pressure ulcer was found on Patient 2's back last night. When asked if she had photographed the pressure ulcer, the RN stated no and added the wound was photographed when the patient was seen by the WCN.

Review of the Skin Care Team Wound Documentation, initial assessment, dated 11/5/12 at 1000 hours, showed the patient had a Stage I pressure ulcer to the left upper back measuring 1.3 cm x 2 cm in size. The skin was red and non-blanching. The recommendations included to turn the patient side to side only to avoid direct pressure at the site. The initial photograph was obtained by the WCN at the time of evaluation.



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3. Patient 10 was admitted to the facility on 10/24/12, with four Stage III pressure ulcers (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to the right ischium (forms the lower and back part of the hip bone). No photographs of the wounds were found in the medical record at the time of admission

The Wound Care Team saw Patient 10 on 10/25/12, and took photographs of the pressure ulcers. The Wound Care Team recommended Patient 10 be turned every two hours from side to side.

The Pressure Ulcer Prevention/Management Nursing Care Plan was not initiated for Patient 10 until 10/25/12. One of the treatment interventions was to avoid positioning the patient directly on pressure ulcer sites when repositioning every two hours. Review of the positioning documentation on the Intensive Care Flowsheets showed the following:

* On 11/3/12, Patient 10 was placed supine for four of the 24 hours, and was positioned on his left side without turning from 1800 to 2300 hours.

* On 11/4/12, Patient 10 was positioned on the left side without turning from 1000 to 1400 hours.

On 11/5/12 at 1025 hours, and again on 11/6/12 at 1050 hours, Patient 10 was observed by the surveyor lying in the supine position. Review of the positioning record for this time period showed Patient 10 was position on his right side, on the site of the pressure ulcers, from 1000 to 1200 hours.

Review of the wound documentation for Patient 10 showed inconsistent documentation of the anatomical site of the patient's pressure ulcers. For example, on 11/3 and 11/4/12, the flowsheet nursing notes showed the patient had Stage III pressure ulcers on the left and right buttocks. On 11/4/12 at 2030 hours, documentation showed the patient had Stage III pressure ulcers on the right buttock and right inner buttock. The nursing notes on 11/5/12 at 0400 hours, showed the site as right buttock.

The care of Patients 2, 10 and 12 were discussed with the WCN during an interview on 11/6/12 at 1330 hours. The WCN stated the WCNs see patients with a Braden score of 12 or less. An order must be entered into the computer by nursing for wound consults. The WCNs also check the computer for high risk patients who could have skin breakdown while hospitalized. The WCNs recommend wound treatments for the patients and see patients once each week to see if treatments are being followed.

The WCN stated a photograph should be taken as soon a patient with a wound is admitted in the ED or by the admission nurse.

When asked if the WCNs participated in educating the nursing staff on staging pressure ulcers and the documentation of anatomical sites, she stated "no" and added the training was done by a nurse educator.

Based on observation, interview and medical record review, the hospital failed to ensure the care plans for five of seven sampled patients' care plans reviewed were individualized, kept current, and implemented to address pressure ulcer prevention and management (Patients 2, 8, 9, 10 and 12). A lack of comprehensive care plan development may result in interventions not initiated which can further compromise the patient's medical status.

Findings:

In February 2007, the NPUAP defined a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

The EPUAP/NPUAP guidelines for the prevention of pressure ulcers state "Reposition frequency will be determined by the individual's tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessment of individual's skin condition." Guidelines developed by the EPUAP/NPUAP for the treatment of pressure ulcers state "The schedule for repositioning the patient should be based on the degree to which the individual is at risk for developing pressure ulcers and on the response of the tissue to pressure. Thus, the higher the risk for additional pressure ulcer and the longer the duration of reactive hyperemia, the more frequently the patient should be repositioned." The guidelines also state "establishing turning frequency based on the characteristic of support surface and the individual's response and "written repositioning schedules should be developed even when patients are using a pressure-reducing support surface."

The hospital's P&P titled Pressure Ulcer Prevention and Management dated 8/18/10, was reviewed on 11/5/12. The stated purpose of the P&P was to ensure initial and ongoing assessments and interventions to maintain or restore skin integrity, prevent skin breakdown and promote healing using the most current and evidenced based clinical guidelines.

A nursing care plan related to skin integrity must be initiated for any patient identified as at risk for pressure ulcer development.

Routine prevention measures for patients at risk for pressure ulcer development (Braden Scale of 13-16) includes minimizing pressure by encouraging patients to reposition frequently (minimally every two hours). Avoid positioning patients directly on pressure ulcer sites.

1. Patient 12 was observed on 11/5/12 at 1430 hours, during a tour of the 6W unit accompanied by the Education Coordinator and the 6W Nurse Manager. The patient was lying in bed and positioned on her back. The patient appeared alert and oriented and when asked, stated she repositioned herself in the bed. The patient stated she had never been told not to lie on her back.

Patient 12's medical record review showed she was admitted to the hospital on 10/26/12, via the ED at 0533 hours. The admission nursing assessment documented the patient had a Stage I and a Stage II pressure ulcers present at the time of transfer from the ED. The picture body diagram showed the Stage I pressure ulcer was located at the sacrococcyx area. The Stage II pressure ulcer was located above the Stage I pressure and slightly to the right of midline.

However, review of the Skin Care Team Wound Documentation dated 10/26/12 at 0900 hours, showed three pressure ulcers were found and assessed after a complete body check of Patient 12 was completed. Site #1 was a Stage II pressure ulcer on the lumbar area measuring 1.2 cm x 1.2 cm x 0.1 cm in size. Site #2 was a Stage I pressure ulcer measuring 7 cm x 8 cm in size on the sacrococcyx. Site #3 was an Unstageable pressure ulcer to the right heel measuring 2.5 cm x 3 cm in size. Photographs of the wounds were taken at that time.

The WCN's recommendations included to turn the patient side to side only and offload the heels from the mattress.

Review of Patient 12's care plan to address Pressure Ulcer Prevention and Management, initiated 10/26/12, did not incorporate the Wound Care Team's recommendation to avoid positioning the patient directly on the pressure ulcer sites. The care plan was not updated to show the presence of the right heel Unstageable pressure ulcer with the directive to offload/elevate the patient's heels off the bed.

Review of the flowsheets for Patient 12 dated 10/27- 11/4/12, showed the patient was consistently turned every two hours; however the patient was alternately positioned left, right and supine where the pressure ulcers were located.

Review of the Skin Care Team Wound Documentation dated 11/5/12 at 0920 hours, showed Site #1, the Stage II pressure ulcer to the lumbar area and Site #3, the Unstageable pressure ulcer to the right heel were somewhat smaller in size; however, the pressure ulcer to the sacrococcyx had increased from a Stage I to a Stage II pressure ulcer measuring 5 cm x 3.5 cm x 0.1 cm in size.

2. Patient 2 was observed during a tour of 3 E accompanied by the Education Coordinator and RN A on 11/5/12 at 0945 hours. Patient 2 was positioned slightly to the right with a pillow wedged behind his left upper back to hold him in place. RN A stated she assessed a new Stage I pressure ulcer on the patient's left upper back at the beginning of her shift that morning.

When the RN was asked to turn Patient 2 to allow observation of the pressure ulcer, the RN was required to turn the patient more to the right side. The site of the pressure ulcer over a bony area was observed in direct contact with the pillow used as a positioning wedge.

A family member at Patient 2's bedside stated the pressure ulcer was assessed by the nurse on the previous night shift. When asked if nursing assisted the patient to turn every two hours, the family member stated she was constantly at the bedside and the patient was turned only about two to three times a shift during his stay on the telemetry unit, although the family member stated on this unit it was more frequent.

Patient 2's medical record review showed an admission date of 10/24/12. The patient's Braden Score was not assessed as high risk at the time of admission as the patient was alert, oriented and able to move around in bed unassisted. However, by 10/29/12, after a change of condition, the patient was transferred to the ICU. The Braden Score was assessed as low as 9 (high risk) as the patient was confined to bed and required moderate to maximum assistance in moving.

Review of Patient 2's care plan to address Pressure Ulcer Prevention and Management, initiated on 10/29/12, showed nursing was to physically reposition and turn the patient every two hours.

Review of the Nursing Flow Sheet dated 11/1/12, showed the patient was positioned supine at 1700 hours. There was no documentation to show the patient was repositioned during the remainder of the evening shift.

Review of the Nursing Flow Sheet dated 11/2/12, showed Patient 2 remained in the supine position from 0600 until 1200 hours. Documentation showed the patient was again positioned supine at 1400 and 1600 hours. There was no documentation to show the patient was repositioned every two hours from 1600 hours through 2300 hours.

Review of the Nursing Flow Sheet dated 11/3/12, showed Patient 2 "self" turned on the night and day shifts, and on the evening shift, documentation showed the patient was assisted to turn every two hours; however, there was no documentation of the position of the patient when turned for all three shifts.

Patient 2 was transferred to 3E on the night shift of 11/4/12. The patient's skin was assessed as intact at the time of transfer. Documentation showed the patient was turned side to side and back every two hours.

Review of the Skin Care Team Wound Documentation, initial assessment, dated 11/5/12 at 1000 hours, showed the patient had a Stage I pressure ulcer to the left upper back measuring 1.3 cm x 2 cm in size. The skin was red and non-blanching. The recommendations included to turn the patient side to side only to avoid direct pressure at the site.


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3. Patient 8's medical record review was conducted on 11/5/12. Patient 8 was admitted from a skilled nursing facility on 11/2/12. The patient's skin was intact. The initial physician's progress notes showed the patient had respiratory failure, a systemic infection, was unresponsive and mechanically ventilated. However, review of the Pressure Ulcer Prevention/Management Nursing Care Plan dated 11/2/12, showed the patient would be encouraged to perform early ambulation as tolerated/ordered; reposition frequently; do active range of motion exercises; and take adequate nutrition and hydration

4. Patient 9's medical record review was conducted on 11/5/12. Patient 9 was admitted from a skilled nursing facility on 11/2/12. The patient was admitted with respiratory distress, was mechanically ventilated and had dementia. However, the Pressure Ulcer Prevention/Management Nursing Care Plan showed the patient was to be encouraged to reposition frequently.

5. Patient 10's medical record review was conducted on 11/5/12. Patient 10 was admitted to the facility on 10/24/12 with four Stage III pressure ulcers to the right ischium (forms the lower and back part of the hip bone). The Wound Care Team recommended Patient 10 be turned every two hours from side to side.

The Pressure Ulcer Prevention/Management Nursing Care Plan for Patient 10 was not initiated until 10/25/12, the day after admission. One of the treatment interventions was to avoid positioning the patient directly on the pressure ulcer sites when repositioning every two hours.

Review of the positioning documentation on the Intensive Care Flowsheets showed the following:

* On 11/3/12, review of documentation showed Patient 10 was in the back lying position without turning for four of the 24 hours and was positioned on his left side without turning from 1800 to 2300 hours.

* On 11/4/12, Patient 10 was positioned on the left side without turning from 1000 to 1400 hours.

On 11/5/12 at 1025 hours and on 11/6/12 at 1050 hours, Patient 10 was observed in his bed, lying in the supine position; however, when reviewed, the positioning record dated 11/5/12, showed Patient 10 was positioned on his right side from 1000 to 1200 hours.

Based on observation and staff interview, the hospital failed to ensure patients with EVD catheters (a catheter inserted by drilling a hole on the skull up to the brain ventricles to reduce the pressure on the brain. It does this by draining fluid from inside the brain to outside the body where it drains off into a collection bag) were not assigned to a nurse whose assignment included patients with infections/potential infections. The pairing of these two types of patients in one nursing assignment created the potential for cross-contamination of bacteria to the patient with the EVD, who was at high risk for infection to the CSF.

Findings:

Review of Clinical Practice Guidelines of the American Association of Neuroscience Nurses on the Care of Patients Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or Lumbar Drainage, under Recommendations on page 13, showed an EVD had the capacity to monitor and control ICP by allowing therapeutic CSF drainage. EVD placement was frequently performed urgently, but care should be taken to maintain sterility.

The number one nursing responsibility after placement of the EVD as stated on page 12, was prevention of infection with strict adherence to aseptic technique. Bacterial ventriculitis and meningitis (bacterial infection of brain ventricles and meninges) is an EVD-associated infection reported frequently, so exposure of the EVD to contamination should be avoided. Since CSF was normally 60% blood glucose/sugar, there was a high likelihood of a bacterial invasion of CSF as bacteria is attracted to glucose.

The ICUs were toured on 11/5/12 at 1030 hours, accompanied by the QA RN. The QA RN explained the ICUs were subdivided according to specialties units. Neuro-surgical patients were placed in 6 West ICU, medical patients were placed in 5 West ICU, patients with heart disorders were placed in 4 West ICU, trauma patients were placed in 3 West ICU and heart/thoracic surgeries were placed in 3 CTCU.

During the tour of the Neuro ICU with the Nurse Manger, RN F, the patient in bed 1 of the seven bed patient ward was observed. The patient had a tube for breathing attached to mechanical ventilation and an EVD catheter from his head to a drainage bag. The patient in bed 2, separated from bed 1 only by a curtain, also had a breathing tube attached to mechanical ventilation. RN F reported the patients in beds 5 and 6 had infections but were not classified as neuro patients. When asked about the placement of the patient in bed 1 with an EVD in the same room along with the patients in beds 2, 5, and 6 with infections, RN F stated the RN assigned to the "clean" patient in bed 1 was only assigned to another "clean" patient, the patient in bed 3. RN F stated, when asked, the patients in beds 2, 5, and 6 were medical patients placed in the Neuro ICU as there were no Medical ICU beds available.

On 11/7/12 at 1000 hours, the Neuro ICU was again toured with RN F. The patient in bed 1 no longer had a breathing tube, and was observed sitting up in a chair placed at the edge of the curtain separating bed 1 from bed 2. The patient continued to have the EVD catheter.

The patient in bed 2, approximately three feet away from the patient in bed 1, was no longer connected to the mechanical ventilator; however, copious amounts of secretions were observed from the tracheostomy (airway opening on the neck). Medical record review showed the patient in bed 2 continued to receive three different IV antibiotics for infection. When asked, RN F stated the patients in beds 1 and 2 were assigned to the same RN.

At 1010 hours, RN F was asked regarding the patient care assignment mixing "clean" and "dirty" patients. RN F stated they did not always have much choice when making the assignments, but nursing was to adhere to strict hand washing techniques. RN F was unable to state if the patients in beds 2, 5, and 6 had positive cultures for bacteria; however, RN F stated each of these overflow medical patients were ordered three to four IV antibiotics. When asked, RN F was not able to provide information as to who should provide oversight on the type of patients cohorted with neuro- surgical patients with an EVD, who were at high risk for infection.

At 1400 hours on 11/7/12, RN D, the Patient Flow Coordinator, was asked who was responsible to make rounds and decide if overflow patients should be transferred to the appropriate unit when beds were available. RN D stated she was to be guided not to mix immune-compromised (very prone to infection) patients with isolation patients and/or with contagious diseases when assigning rooms to admitted patients. However, RN D stated she was not expected to make rounds and determine patient placements to vacant beds after admission.

On 11/7/12 at 1500 hours, RN G, the Nurse Educator, was asked how nursing patient assignments should be made in the Neuro ICU with regards to cross contamination. RN G stated, "Efforts should be made to separate dirty from clean patients."

Based on record review and interview, the hospital failed to ensure the completion of the medical records for three of 39 sampled patients (Patients 3, 27 and 28).

Findings:

1. Patient 3's medical record was reviewed on 11/5/12. The patient visited the ED on 9/30/12. Review of ED Record on Page 3 of 3, Condition on Disposition, showed the resident physician's signature. Two attending physicians signed they reviewed the case and agreed with the findings of the resident. The form did not include a space for documentation of the date and the time of the signatures.

On 11/5/12 at 1100 hours, during an interview, MD 1 reviewed the medical record for Patient 3. MD 1 confirmed the ED Condition on Disposition form did not have a space to document the time and date of the attending physician's signature.

2. Patient 27's medical record was reviewed on 11/7/12. Patient 27 came to the hospital for an outpatient surgical procedure on 10/23/12 at 1015 hours, and was admitted to the ICU for further medical management.

Review of an Informed Consent for Common Procedure in the ICU for Patient 27, showed the consent was signed by two physicians. MD 2 signed on the patient/parent/conservator/guardian section; however, the areas for date and time were left blank. A second signature by another physician on the witness section showed the time was documented "10/23/12 at 09:00," (previous to the patient's arrival at the hospital).

On 11/7/12 at 1155 hours, MD 2 was interviewed. MD 2 stated the patient was admitted with an emergency critical condition. The hospital's P&P showed when the patient was not competent to sign the informed consent, two physicians signed on the patient's behalf. MD 2 stated he signed the document in a hurry and did not document the date and time. MD 2 was unable to state why the second physician documented the time previous to the patient's admittance.

3. Patient 28's medical record was reviewed on 11/6/12. The Procedure Sedation Documentation Record, Patient Assessment, dated 11/6/12, showed the physician signed the form but did not complete the date of the signature.

Based on medical record review, the hospital failed to ensure an updated history and physicial was completed prior to a procedure for one of 39 sampled patients (Patient 28). This resulted in the potential for changes in the patient's medical condition to not be communicated to the patient's caregivers.

Findings:

Patient 28's medical record was reviewed on 11/6/12. The Pre-Endoscopy Evaluation Form areas for documentation of the patient's surgical history, allergies to medications, a physical examination for vital signs, and pre-procedure laboratory results were left blank.

Based on interview and medical record review, the hospital failed to ensure a consultation evaluation was documented for one of 39 sampled patients (Patient 3).

Findings:

On 11/5/12 at 1100 hours, MD 1 stated consultations for ED patients should be documented on the patient's medical record, either electronically or on paper.

Patient 3's medical record was reviewed on 11/5/12. Patient 3 came to the hospital's ED on 9/30/12, complaining of a foreign body in the throat.

Patient 3's medical record was reviewed on 11/5/12. Patient 3 came to the hospital's ED on 9/30/12, with complaints of a foreign body in the throat. The ED Record showed documentation by the resident physician in the medical decision area, the "ENT agreed not to scope and follow up if symptoms persist." However, there was no documentation to show the findings of ENT (ear, nose and throat) consultation in the medical record.

Based on observation, the hospital failed to ensure proper infection control was maintained in four of thirty observations made for infection control practices in the facility. These failures increased the potential for the transmission of infection to patients, staff and visitors.

Findings:

1. On 11/5/12 at 1000 hours, the clean supply room in the Neuro ICU was observed. An IV pole was sitting in the corner of the room between two racks of clean supplies. A half full 250 ml size IV bag of normal saline was hanging on the IV pole, with the tubing used for administration of the saline still attached to the bag. An orange label on the bag showed the medication was for Patient 18 and was dated 10/19/12, 26 days prior to the observation.

Review of Patient 18's medication record showed physician's orders for Patient 18 dated 10/19/12, to receive normal saline at 25 mL per hour.

2. On 11/5/12 at 1025 hours, a physician was observed on the Medical ICU in Patient 11's room. There was a sign outside the door of the room showing the patient was on contact isolation precautions. The physician's long hair was not secured and fell forward, coming in close contact with possibly contaminated items as she leaned over the patient. The physician was wearing a gown and gloves per hospital contact isolation policy. However, the gown had not been secured at the neck. As the physician leaned over and examined the patient, the neck of the gown came loose and the front and arms of the physician's white lab coat and clothing underneath were exposed to possible contamination by contact with the patient, the bed siderails and bedding. Review of Patient 11' s medical record showed the patient was placed on contact isolation for possible sepsis and lice infestation.



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3. During an observation on 11/5/12, at 1030 hours, in the surgical subspecialty clinic, an RMS was observed to take off her gloves while leaving a patient room. The RMS was not observed to wash her hands or use a hand sanitizer after removing her gloves. The RMS proceeded to two additional patient rooms without an observation of hand washing or use of an alcohol based hand sanitizer.


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4. On 11/4/12 at 1055 hours, during an ED tour, a group of physicians walked out of a patient care unit. One of the physicians in the group removed a pair of gloves, disposed of them in the trash can, and walked out the door of the ED. No hand hygiene was performed.