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Based on hospital policy and procedure review, grievance file review, and complainant and staff interview, the hospital staff failed to provide written notice of the resolution of the grievance in 1 of 1 grievances reviewed (grievance for patient #2).

Findings include:

Review of hospital policy and procedure, with a revision date of 09/30/2008, entitled "Patient Grievance Process" under I. Policy: ..."that a mechanism be provided by the Service Excellence Department, appropriate staff members and department managers to receive and respond to patient' and/or families' perceptions regarding their quality of care."...also under III Procedure: C..."Complaints should be promptly investigated and a response should be given to the patient within sixty (60) days. If the nature of the complaint/grievance should require longer than sixty (60) days to investigate, the complainant should be advised of the extension and when he/she should receive a response. All grievances shall be responded to in writing upon resolution and will include the steps taken to investigate the grievance, the results of the grievance process, date of completion, and the name of the contact person..."

Review of the grievance for patient #2, submitted by the patient's daughter and son on 01/11/2010 with concerns about the lack of care the patient was receiving when he needed assistance with toileting. Review of the grievance file showed an investigation had taken place and a letter had been sent to the patient, however no documented notification was given to the complainants. Phone interview with the complainant on 02/05/2010 at 0845 revealed he had not received any letter or notification of the resolution to his complaints.

Interview with the hospital Service Excellence Department representative on 02/04/2010 at 1000 revealed letters are sent to patients and not other family members. The interview also revealed the hospital had no system in place to inform complainants (when not the patient) how investigation resolutions would be reported back to the complainant.

Based on medical record review and staff interview, nursing staff failed to supervise and evaluate nursing care as evidenced by failing to ensure daily weight was monitored as ordered by the physician for 2 of 3 records reviewed of patients requiring daily weights (#1 and #9).

Findings include:

1. Closed record review on 02/03/2010 of Patient #1 revealed an 81 year-old female admitted 01/07/2010 for pneumonia. Review of the record revealed the patient was discharged 01/15/2010. Review of the record revealed a physician's order dated 01/07/2010 at 1746 to weight patient now and another physician's order dated 01/13/2010 at 1148 to weight the patient daily. Review of a nursing care plan dated 01/12/2010 revealed an identified problem with fluid excess and electrolyte imbalance with interventions that included daily weight to be monitored. Review of the record revealed the patient was weighed on 01/08/2010. Further review of the record revealed no evidence of further weights documented.

Interview on 02/03/2010 at 1510 with nursing administrative staff revealed the patient should have been weighed daily based on the physician's orders and the nursing care plan. Interview revealed there was no evidence that the patient was weighed on 01/12/2010, 01/13/2010, 01/14/2010 and 01/15/2010 (four of four days). Interview confirmed nursing staff failed to monitor the patient's weight as ordered.

2. Open record review on 02/04/2010 of Patient #9 revealed a 76 year-old female admitted 01/26/2010 for congestive heart failure and end stage renal disease. Review of the record revealed a physician's order dated 01/26/2010 to weight the patient daily. Review of the record revealed the patient was weighed on 01/26/2010, 01/27/2010, 01/28/2010, 01/29/2010, 01/31/2010, 02/03/2010 and 02/04/2010. Further review of the record revealed no weights documented on 01/30/2010, 02/01/2010 and 02/02/2010 (three of ten days).

Interview on 02/04/2010 at 1130 with nursing administrative staff revealed the patient should have been weighed daily based on the physician's order. Interview revealed that the patient was in a "total care bed" that allowed patients to be weighed while lying in the bed. The staff member stated there was no reason why the patient couldn't have been weighed and that even if the bed weight was not working, the patient could have been weighed with a sling weight. Interview revealed there was no evidence that the patient was weighed on 01/30/2010, 02/01/2010 and 02/02/2010. Interview confirmed nursing staff failed to monitor the patient's weight as ordered.

Based on review of hospital policy and procedures, medical record review and staff interviews the nursing staff failed to administer blood transfusions according to hospital policy for 2 of 3 sampled patients that received a blood transfusion (#5 and #4).

The findings include:

Review of the "Administration of Blood and Blood Components" policy revised June 2009 revealed "...E.11. The patient should be closely monitored during the first 15 minutes of the transfusion to observe for signs of transfusion reaction/complication. 12. Record pulse, respiratory rate, blood pressure, and temperature 15 minutes after initiation of transfusion, hourly during the transfusion, and upon completion of the transfusion. ...G. 1. Vital signs including Temp, BP (blood pressure), pulse and Respiratory rate should be recorded at the following intervals for all transfusions: a) Pre-transfusion (within 20 minutes of the start time) b) 15 minutes after initiation c) hourly during transfusion d) post transfusion...."

1. Closed record review on 02/03/2010 of Patient #5 revealed a 62 year-old male admitted on 12/11/2009 for leukemia. Record review revealed the patient was discharged on 01/26/2010. Record review revealed a physician's order dated 12/16/2009 at 0956 to transfuse two units of packed red blood cells over one hour each unit. Record review revealed the second unit of blood was started on 12/16/2009 at 1720 and completed at 1835. Record review revealed the nurse assessed the patient's TPR (temperature, pulse and respirations) and BP (blood pressure) at 1659, 1735 and 2320 (5 hours and 45 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs hourly during the transfusion and at the completion of the transfusion at 1835. Record review revealed a physician's order dated 12/19/2009 at 0955 to transfuse two units of packed red blood cells over one to two hours each unit. Record review revealed the first unit of blood was started on 12/19/2009 at 1240 and completed at 1410. Record review revealed the nurse assessed the patient's TPR and BP at 1246 (6 minutes after the blood transfusion was started), 1304 (24 minutes after the transfusion was started), 1404 and 1420. Record review revealed no assessment of vital signs prior to starting the transfusion and 15 minutes after the transfusion was started. Record review revealed the second unit of blood was started on 12/19/2009 at 1430 and completed at 1600. Record review revealed the nurse assessed the patient's TPR and BP at 1420 and 1622 (2 hours and 2 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs 15 minutes after the transfusion was started and hourly during the transfusion. Record review revealed a physician's order dated 12/22/2009 at 0840 to transfuse two units of packed red blood cells. Record review revealed the first unit of blood was started on 12/22/2009 at 1145 and completed at 1315. Record review revealed the nurse assessed the patient's TPR and BP at 1140, 1207 (22 minutes after the blood transfusion was started) and 1317 (1 hour and 10 minutes after prior vital signs). Record review revealed no assessment of vital signs 15 minutes after the transfusion was started and hourly. Record review revealed the second unit of blood was started on 12/22/2009 at 1345 and completed at 1525. Record review revealed the nurse assessed the patient's TPR and BP at 1317, 1356 and 1708 (3 hours and 12 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs hourly during the transfusion and at the completion of the transfusion. Record review revealed a physician's order dated 12/26/2009 at 0930 to transfuse two units of packed red blood cells. Record review revealed the first unit of blood was started on 12/26/2009 at 1545 and completed at 1715. Record review revealed the nurse assessed the patient's TPR and BP at 1515, 1614 (29 minutes after the blood transfusion was started) and 1728 (1 hour and 13 minutes after prior vital signs). Record review revealed no assessment of vital signs 15 minutes after the transfusion was started and hourly during the transfusion. Record review revealed the second unit of blood was started on 12/26/2009 at 1730 and completed at 1850. Record review revealed the nurse assessed the patient's TPR and BP at 1728, 1813 (43 minutes after transfusion started) and 2338 (5 hours and 25 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs 15 minutes after the transfusion was started, hourly during the transfusion and at the completion of the transfusion. Record review revealed a physician's order dated 12/28/2009 at 0929 to transfuse two units of packed red blood cells. Record review revealed the first unit of blood was started on 12/28/2009 at 1125 and completed at 1255. Record review revealed the nurse assessed the patient's TPR and BP at 1101, 1137 and 1307 (1 hour and 30 minutes after prior vital signs). Record review revealed no assessment of vital signs hourly during the transfusion. Record review revealed the second unit of blood was started on 12/28/2009 at 1320 and completed at 1500. Record review revealed the nurse assessed the patient's TPR and BP at 1307 and 1704 (3 hours and 7 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs hourly during the transfusion and at the completion of the transfusion. Review of the record revealed vital signs were not assessed according to the hospital's policy.

Interview on 02/04/2010 at 1030 with administrative nursing staff revealed the patient's vital signs were not assessed prior to starting the transfusion on 12/19/2009, 15 minutes after starting the transfusions on 12/19/2009, 12/22/2009 and 12/26/2009, hourly during the transfusions on 12/16/2009, 12/22/2009, 12/26/2009 and 12/28/2009 and at the completion of the transfusions on 12/16/2009, 12/22/2009, 12/26/2009 and 12/28/2009. Interview confirmed the nursing staff did not follow the hospital's policy for the administration of blood.

2. Closed record review on 02/03/2010 of Patient #4 revealed a 62 year-old female admitted on 12/13/2009 for abdominal pain. Record review revealed the patient was discharged on 01/12/2010. Record review revealed a physician's order dated 01/03/2010 at 0903 to transfuse one units of packed red blood cells. Record review revealed the first unit of blood was started on 01/12/2010 at 1845 and completed at 2100. Record review revealed the nurse assessed the patient's TPR (temperature, pulse and respirations) and BP (blood pressure) at 1838, 1936 (51 minutes after the transfusion was started) and 2206 (2 hours and 30 minutes after prior vital signs assessed). Record review revealed no assessment of vital signs 15 minutes after the transfusion was started, hourly during the transfusion and at the completion of the transfusion. Review of the record revealed vital signs were not assessed according to the hospital's policy.

Interview on 02/03/2010 at 1330 with administrative nursing staff revealed the patient's vital signs were not assessed 15 minutes after starting the transfusion on 01/03/2010, hourly during the transfusion and at the completion of the transfusion. Interview confirmed the nursing staff did not follow the hospital's policy for the administration of blood.

Telephone interview on 02/03/2010 at 1340 with the registered nurse that administered the blood on 01/03/2010 revealed the patient's vital signs should be assessed 15 minutes prior to starting the blood transfusion, 10 to 15 minutes after the transfusion is started, hourly during the transfusion and at the completion of the transfusion. Interview with the nurse revealed that she could not explain why the vital signs were not assessed according to the hospital's policy.