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Based on interview, document review, and observation, the hospital failed to inform admitted patients whom to contact to file a grievance. Findings include:

<1> Unit observations on 4/12/10 and 4/13/10 revealed posting of signage listing advocacy agencies that may assist a patient in filing a patient rights complaint. The listing included the Center for Medicare/Medicaid Services' (CMS) 800 complaint hot line number.

CMS is not an advocacy agency but a regulatory agency that will investigate, as applicable, received complaint allegations. The signage did not specifically note a patient's right to file a grievance with CMS regarding an allegations of abuse, neglect, deficiency in the quality of care, or failure to comply with hospital Medicare requirements (Conditions of Participation).

<2> On 4/12/10 a copy of the patient rights booklet regarding the hospital's grievance process and patient rights that is included in the admission packet that is provided to an admitted patient or patient representative was reviewed Review revealed that the patient rights booklet included contact information for the hospital's patient rights staff and phone numbers of a number of advocacy agencies. The patient rights booklet did not include information regarding: (1) the patient or patient's representative right to file a complaint with CMS regarding an allegation of abuse, neglect, deficiency in the quality of care, or failure to comply with hospital Medicare requirements (Conditions of Participation), (2) the CMS 800 complaint hot line number, and (3) CMS complaint mailing address.

Based on document review and interview, the hospital failed to ensure that the grievance process included a mechanism for timely referral of a Medicare beneficiary's concerns regarding quality of care to the appropriate Utilization and Quality Control Quality Improvement Organization (QIO). Findings include:

<1> The hospital's Patient Right Protection and Grievance Resolution policy/procedure (Statement #223) was reviewed. Review revealed that Procedure Section #9 of the policy/procedure states that a Medicare beneficiary has "the right to forward their complaint to the Michigan Peer Review Organization (MPRO, the local QIO)." The policy/procedure does not specify the hospital's mechanism for the timely referral of a Medicare beneficiary's concerns regarding quality of care if the Medicare beneficiary wants the hospital to forward to the QIO his/her quality of care concerns.

<2> The hospital's risk manager/compliance officer (RM/CO) was interviewed 4/13/10 regarding the information that was provided to patients regarding a Medicare beneficiary's right to have his/her quality of care complaint referred to the QIO. The RM/CO stated that recipient rights summary investigative grievance resolution reports signed by the hospital director and sent to complainants include the information that a Medicare beneficiary has the right to forward their complaint to MPRO. The recipient rights summary investigative greivance resolution reports do not reference the provision that the beneficiary may request that the hospital forward to the QIO the beneficiary's quality of care complaint.

The interviewed RM/CO also confirmed that recipient rights intervention letters signed by the hospital's rights advisor do not include any information regarding a Medicare beneficiary's right to reffer his quality of care complaint to the QIO or ask the hospital to forward to the QIO the beneficiary's quality of care complaint.

The facility failed to provide appropriate nursing monitoring and response to the presentation of medical conditions. See tag A 395.

Based on document review and interviews, the facility failed to monitor and appropriately evaluate, monitor patient responses to treatment and report the pain of 1 (#12) of 1 patients with a terminal diagnosis. Findings include:

On 11/20/09 patient #12 was admitted to the facility with a diagnosis of of Stage III non- small cell carcinoma of the right lung with involvement of both hilar and mediastinal lymph nodes. The physicians's long-term goal was to "maintain patient pain free." For pain control, patient #12 was receiving Vicodin Extra Strength (ES), 2 tablets every 6 hours PRN (as needed) and Morphine Sulfate, 30 mg twice daily PRN. The MD's interventions were to assess his pain periodically and adjust medications. Patient #12 also had a diagnosis of chronic back pain. For back pain, he had orders for Motrin 400 mg. 4 times daily PRN and Vicodin Extra Strength (ES) 2 tablets every 6 hours PRN. The Pain Assessment, done at admission, indicated pain occurring all day, radiating to both upper arms, described as an ache, at a usual intensity of 8-10 (on a 10-point scale.) Patient #12 was referred to the rehab department for treatment related to pain and mobility issues.

In the Admission Individual Plan of Service (IPOS) completed 11/25/10, the nursing intervention for goal #2 (pain) states: "The RN/LPN will meet with the patient weekly for one hour. During this one-to-one meeting, the RN will assess the effectiveness of the pain medication." Review of the patient's record did not reveal documentation of a weekly RN-patient discussion regarding pain and the effectiveness of pain medication provided.

On 1/15/10, the OT (Occupational Therapist) stated, "patient reports significant pain." On 1/19/10, the (OT) noted "concerns with patient pain level. Per Dr. discontinue OT/PT treatment and Dr. will review/adjust pain meds. Will f/u (follow-up) in 30 days."

From 1/13/10-1/19/10, 2 tablets of Vicodin had been given 1-3 times daily . A pain level of 10 (worst possible) was noted on 1/13/10, 1/15/10, 1/16/10, 1/17/10, and 1/18/10.

On 1/19/10 the physician ordered that the patient's Vicodin order be changed from 2 tablets every 8 hours to 1 tablet every 6 hours PRN for 4 weeks. 1 additional tablet was allowed for breakthrough pain, not to exceed 5 tablets per day. The change reduced the total amount of Vicodin ordered PRN per day from 6 tablets to 5 tablets

After 30-days, the above order ended, reducing the frequency of the PRN Vicodin ES order to every 6 hours PRN, eliminating the extra tablet allowed for breakthrough pain. There was no pain assessment done or documentation to indicate why the order was not renewed.

Review of the Medication Administration record revealed that patient #12 received Vicodin 1-3 times a day each day from 1/27/10-2/16/10. He had used the Vicodin for break-through pain on 2/1, 2/6/10, 2/8/10, 2/11/10 and 2/14/10. His pain ranged from 8-10, with 10 being the most frequent rating. From 2/1/10-2/16/10, he awakened in the night with pain (ranging from 8-10) on 2/1/10, 2/2/10, 2/3/10, 2/4/10, 2/6/10, 2/8/10, 2/11/10, 2/14/10, and 2/16/10.

On 2/17/10 the efficacy of the Vicodin ES was not documented on the Medication Administration Record after administration. On 2/16/109, 2/21/10, 2/22/10 and 2/23/10 patient #12's pain location was documented as "body pain" only. Nursing documentation did not specify the location or quality of the pain. Although possible accompanying symptoms (per the facility pain assessment form) of irritability and anger were often documented, there was no documentation to indicate that these symptoms were considered as possible manifestations of pain.

A physician's note, dated 2/18/10 lists problems of dysphagia, lung cancer, back pain and diarrhea. Patient #12 was experiencing episodes of coughing and choking when eating and diarrhea related to a diagnosis of C-Difficile, acquired since admission.

A "Routine Nursing Care Progress Note," dated 2/21/10, stated, "patient is on Vicodin ES PRN for pain and Tylenol 650 mg. every 4 hours for pain. The Tylenol was ordered PRN for temperature above 100 degrees and had not been given at all in February 2010. The nurse stated, "patient is able to verbalize his pain and request the meds and mostly the medications have good effect on him." There was no futher pain assessment noted.

The "RN's Monthly Summary," dated 2/21/10, states"nurses are monitoring patient for complaints of pain." There is no mention of the patient's daily complaints of pain ranging from 8-10 or awakening in pain most nights. A complete pain assessment had been done since admission.

On the IPOS's completed on 11/25/09 and 2/25/10, the patient's SPO2 (oxygen) saturation was to be monitored as part of the pain relief goal, with the potential for pain, shortness of breath and wheezing. On 2/10/10 the physician ordered that vital signs be taken Monday, Wednesday and Friday. On 2/19/10 and 2/22/10 neither respirations nor SPO2 assessments were documented on the patient's Vital Signs Sheet.

The last dose of Vicodin ES administered to patient #12 was on 2/28/10 at 1830. At 1950 he rated his pain as 5 out of 10. There is no documentation of any follow-up action to this rating. The patient was found dead on 3/1/10. Above findings were confirmed by the Director of Nursing.

According to the facility policy on Pain Management (#267), "The patient experiencing pain will be appropriately assessed and interventions will be made in a timely manner to provide pain relief. If treatment is ineffective, treatment plan shall be modified."