HospitalInspections.org

Based on review of hospital documents, surveyor observations and interviews with staff, the hospital failed to ensure patients/patients' representatives are informed whom to contact to file a grievance and to notify patients/patients' representatives that they have the right to file a grievance with the State agency.

Findings:

1. The Patient's Rights handout given to the surveyors on the morning of 03/02/2010 and those observed on at two patient bedsides did not contain information to inform patients/patients' representatives of the above information.

2. These findings were discussed with administrative staff on the morning of 03/02/2010 when the patient rights handout was provided and again at the exit conference on the afternoon of the same day. Administrative staff told the surveyors that the prior booklet, which contained the required information, told the surveyors that the booklet was in the process of being updated and that it had been temporarily replaced with the sheet given to surveyors and patients.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients with special and complex needs have nurses assigned that have the specialized qualifications needed to care for these patients. One of five registered nurse files ( RN ) personnel files reviewed did not have evidence of orientation and training in critical care nursing.

Findings:

1. Oklahoma Licensure requirement 310:667-15-7 Special Care Units (e) "all nursing personnel shall be prepared for their responsibilities in the special care unit through orientation, ongoing inservice training, and continuing education programs. A planned, formal training program shall be required for registered nurses and licensed practical nurses and shall be of sufficient duration and substance to cover applicable patient care responsibilities in the special-care unit".

2. One of five registered nurses' personnel files reviewed, who worked intensive care unit (ICU), did not demonstrate the nurse had been oriented to the ICU. The only orientation documentation in the nurse's education file was for "nurse extern orientation". This was the same nurse who was mentioned in the patient grievance.

3. On 3/2/2010 at 1:30 p.m. the ICU Manager confirmed the nurse did not have the ICU orientation and training documented in the education file. The Nurse Manager stated during his investigation of the grievance/incident he found the education files lacking many of the orientation documents. The Nurse Manager stated he had taken over the education role in the ICU after reviewing the education files for this grievance/incident.