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Based on interview and policy review, the facility failed to implement their policy and procedure for complaints/grievance for 1 of 4 patients (patient #1) resulting in the potential for less than optimal outcomes for patient #1.
Findings include:

On 6/21/2021 at 1300 a review of the facility's complaints and grievance logs revealed there were no complaints submitted on behalf of patient #1.

Medical record review on 6/21/2021 at 1330, revealed the patient of concern (#1) was a 57-year-old male who was admitted to the facility on 07/29/2020. The patient was transferred to a higher level of care on 8/13/2020. Review of the admission nursing assessment revealed the patient (#1) did not have any pressure injuries on admission. The patient was subsequently intubated on 7/30/2020 and remained intubated throughout the duration of his stay.

Review of nursing notes dated 8/12/2020 at 1107 documented the patient was observed with four (4) Stage II pressure injuries (health care acquired). Wound #1; bilateral sacrum 13 cm x 10 cm. Wound #2; right shoulder 11 cm x 8 cm. Wound #3; right upper arm 10 x 8 cm. Wound #4; right posterior thigh 2 cm x 2 cm. There was no evidence that documented the physician nor the patient's family was notified of the changes in the patient's skin integrity.

On 6/22/2021 at 1040 Nurse Manager Staff I was interviewed about patient #1. Staff I was asked if he had received any complaints and/or grievances on behalf of patient #1. Staff I replied he had. Staff I said he was not sure who the messages were from. He said there were many. He said it may have been his (#1's) wife or mother. He said he was not sure who the caller was. He explained it took him awhile to get back with the person. According to Staff I, he said, he recalled speaking with her for about 45 minutes. Staff I said, after speaking with the person he told her that he would look into it. Staff I said he recalled her saying, "I don't want this to go any further." Staff I was asked to explain how he "looked" into it. Staff I was asked to provide notes, email, and/or any submitted reports that demonstrated how he addressed the concerns that were brought to his attention on behalf of the patient. He said he did not have any.

On 6/22/2021 at 1600 an interview was conducted with the Chief Nursing Officer Staff A who confirmed a complainant/grievance should have been entered on behalf of the patient (#1).

Review of the facility's "Patient-Family Complainant And Grievance Process", dated last revised on 5/2021 documented the following:

Definition: A..."4. Patient complaints that are considered grievances also include situations where a patient or patient's representative telephones the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the visit are not required to be defined as a grievance.
5. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements.
6. Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all CMS requirements apply..."


Policy:
"..B. The hospital must inform the patient and/or the patient's representative (as allowed under State law) of the hospital's grievance process, including whom to contact to file a grievance (complaint). As part of its notification of patient rights, the hospital must inform the patient or the patient's representative that he/she may lodge a grievance with the State of Michigan Complaint Hotline for the Bureau of Community and
Health System directly, regardless of whether he/she has first used the hospital's grievance process.
(482.13(a)(2)
1. The hospital will provide the patient or the patient's representative with the telephone number and address for the State of Michigan Complaint Hotline for the Bureau of Community and Health
System, The Joint Commission, Livanta, and if applicable, other regulatory facilities. The Michigan Peer Review Organization (MPRO) and if applicable, the Healthcare Facilities Accreditation Program
(HFAP).
C. The hospital must start an investigation of a complaint that alleges abuse, neglect, serious injury, harm,
impairment, or death immediately. The hospital must start an investigation of a complaint that does not allege serious injury, harm, impairment or death as soon as possible and no later than 7 business days of receipt of the complaint. (482.13(a)(2)(ii)

1. All associates are expected to respond to patient and family concerns by taking appropriate action to immediately resolve the issue and/or communicate the concern to the person responsible for that area of the hospital. It is the policy of Ascension to resolve patient/family concerns at the departmental level whenever possible.
2. Patient/family concerns that cannot be resolved by the associate or manager/director should be referred immediately via telephone or other means of immediate communication to the Patient Relations Department..." However, there was no evidence that this was done.

Based on interview and record review, the facility failed to notify the patient's responsible party of changes in skin condition for one (#1) of three patients reviewed for patient rights, resulting in the potential for less than optimal outcomes for patient #1.
Findings include:

Review of the medical record for patient #1 on 6/21/2021 at 1300 revealed the following:
Patient #1 was a 56-year-old-male who was admitted to the facility on 7/29/2020 with diagnoses that included acute hypoxemic respiratory failure. The patient was transferred to a higher level of care facility on 8/13/2020 at 0015 via EMS air.

According to the History and Physical (H&P) dated 7/31/2021 the patient was intubated, sedated and not following commands.

Review of provider critical care progress notes dated 8/12/2020 at 0800 revealed the provider was at the patient's bedside and the following was documented:
Physical examination:
General Impression: Sedated on ventilator (vent)...Neurological: unable to assess, sedated on vent. Withdrawals to pain. Pupils equal and reactive to light.
Plan: "...Awaiting a bed transfer at (name of higher level of care facility) for transfer. Will update family at bedside."

Further review of the medical record revealed the patient (#1) did not have any pressure injuries on admission nor through 8/11/2020.

Review of nursing notes dated 8/12/2020 at 1107 documented the patient was observed with four (4) Stage II pressure injuries all healthcare acquired. Wound #1, bilateral sacrum 13 cm x 10 cm. Wound #2, right shoulder 11 cm x 8 cm. Wound #3, right upper arm 10 x 8 cm. Wound #4, right posterior thigh 2 cm x 2 cm.

However, there was no evidence in the medical record that documented the patient's responsible party was informed of the change in the patient's skin integrity.

On 6/22/2021 at 1000 an interview was conducted with Registered Nurse Staff L. At that time she confirmed she was the author of the aforementioned nursing note dated on 8/12/2020. Staff L was asked if she notified the physician or the patient's responsible party of the change in the patient's skin integrity. At that time, she explained she did not recall. However, at that time she replied she probably should have as well as documented it.

On 6/22/2021 at 1600 an interview was conducted with the Chief Nursing Officer Staff A who confirmed the physician as well as family should have been notified of the patient's change in his skin integrity.

Review of the facility's "Patient Rights and Responsibilities" policy dated last revised on 9/2019 documented the following:
Definitions:
Patient Surrogate: Anyone legally authorized to speak on behalf of a minor (e.g. parents), or on behalf of an adult who does not have decision-making capacity (e.g. patient advocate, legal guardian, next of kin).
Policy:
As a patient at an (name of facility), you have the right:
A. To be involved in decisions about the care, treatment, and services provided. These decisions include the right to receive or refuse care, treatment, and services without coercion, discrimination or retaliation, or having someone of your choice exercise your rights if you are incapable of doing so, in accordance with laws and regulations. You will be asked to consent to treatment or services that have been explained to you in terms you understand...
D. To be informed about the outcomes of the care, treatment, and services provided, including any unexpected outcomes..."
However this was not done.

Based on interview and record review, the facility failed to ensure a registered nurse 1) supervised and evaluated nursing care for one patient (#1) and 2) failed to implement their policy and procedure for wound care management for two (#'s 1 and 5) of 11 patient's reviewed for nursing services and within acceptable standard of practice resulting in the potential for unrecognized, unmet patient needs and the potential for harm for patients # 1 and #5. Findings include:

See Specific Tags:

A-0395 Based on interview and record review the facilty failed to ensure that a Registered Nurse notified the physician and obtained wound care orders for health care acquired pressure injuries, and failed to follow policy and procedure for wound care management.

Based on record review and interview, the facility failed implement their policy and procedure for obtaining wound care orders for a hospital acquired pressure injuries for one patient (#1)and failed to evaluate wound status and perform wound care treatment for wounds that were present on admission per policy and procedure for one (#5) of three patients reviewed for impaired skin integrity, resulting in unmet care needs.
Findings include:

Medical record review on 6/21/2021 at 1330, revealed the patient of concern (#1) was a 57-year-old male who was admitted to the facility on 07/29/2020. The patient was transferred to a higher level of care on 8/13/2020. Review of the admission nursing assessment revealed the patient (#1) did not have any pressure injuries on admission. The patient was subsequently intubated on 7/30/2020 and remained intubated throughout the duration of his stay.

Review of nursing notes dated 8/12/2020 at 1107 documented the patient was observed with four (4) Stage II pressure injuries (health care acquired). Wound #1; bilateral sacrum 13 cm x 10 cm. Wound #2; right shoulder 11 cm x 8 cm. Wound #3; right upper arm 10 x 8 cm. Wound #4; right posterior thigh 2 cm x 2 cm. There was no evidence that documented the physician was notified of the changes in the patient's skin integrity. There were no orders for wound care treatment. There was no consultation for wound care the facility's wound care nurse.

An interview was conducted with patient #5 on 6/22/2021 at 1210 while accompanied by Registered Nurse Staff N. The patient said he did not know how he got the sore on his bottom. The patient was asked by the surveyor if he was being turned and/or repositioned often. He replied, "no". He said they tell you they are going to turn you every 2 hours but they don't. He said they don't come back when they say they will.

Review of the medical record for patient #5 was conducted on 6/22/2021 at 1300 and revealed the following:
The patient (#5) was admitted to the facility on 6/11/2021 with diagnoses that included Sepsis and Urinary Tract Infection. Review of the History and Physical dated 6/11/2021 documented the following:
74-year-old male with previous medical history of chronic lymphedema, diabetes mellitus with severe peripheral neuropathy and history of recurrent foot ulcers...Patient reported he had not been able to do dressing changes on his known decuibtus ulcer on his sacrum and he had not been doing frequent dressing changes of his left heel. Patient reported the last change was 4 days ago.
Assessment/Plan:
"...Wound care...
Review of Systems:..Wound on sacrum and feet.."

Review of Podiatry Consultation dated 6/12/2021 documented:
Assessment/Plan:
"Left foot, heel full-thickness ulceration, stable..X-ray left foot-no soft tissue gas or osteomyelitis present...Patient evaluated at bedside regarding left foot ulcer...Patient will be monitored by podiatry while in hospital...Further recommendations to follow."

Review of Podiatry Progress note dated 6/13/2021 documented:
"...Full-thickness ulceration at inferior aspect of calcaneus, heel stable...
Dry dressing, 4 x 4 with Betadine solution applied to left foot podiatry will treat with local wound care for now...Podiatry
will evaluate right heel Mon/Wed/Fri..."

Review of Podiatry Progress note dated 6/14/2021 documented:
"...Ulceration to the left foot is clinically stable. There are no signs of acute infection present. Applied Betadine and dry sterile dressing to the Ulceration..."

Review of Podiatry Progress note dated 6/16/2021 documented:
"...Patient seen and evaluated...Podiatry will be signing off. Consult has been placed for local wound care..."

Review of Wound Care Consultation dated 6/14/2021 documented:
"System generated consult to wound ostomy care nurse (WOCN), Podiatry team is following patient for left foot wound. WOCN team will sign off services at this time. Please call WOCN team at (contact number) or place new wound care consult with any questions or concerns."

There was no further evidence in the medical record that documented the patient was assessed or evaluated by the WOCN for the sacral wound or his left foot ulceration. There was no evidence in the medical record that documented the patient's sacral wound was measured. There were no evidence in the medical record that nursing staff obtained treatment orders for the patient's sacral wound. There was no evidence in the medical record that documented the patient's left heel was assessed and or treated. There were no evidence in the medical record that nursing staff obtained treatment orders for the left heel ulcer.

Additionally, review of skin assessments for patient #5 dated 6/15/2021 revealed the patient had a Stage III sacral pressure injury. However, there were no measurements documented.

On 6/22/2021 at 1600 during an interview with the Chief Nurse Officer when queried regarding the aforementioned concerns. At that time, she confirmed staff did not follow their policy for skin management and prevention of pressure injury.

Review of the facility's "Pressure Injury Prevention, Management and
Treatment" PolicyStat ID: 8880623, dated last revised on 11/2020 documented the following:

1. Wound measurement must be completed upon admission and at least once every 7 days and as needed if there is significant change to the wound/ pressure ulcer.
a. Document wound assessment in the patient medical record.
2. Measuring the wound
· Measure the length "head-to-toe" at the longest point
· Measure the width side-to-side at the widest point
· Measure the depth at the deepest point of the wound
· All measures should be in centimeters
3. Moisten a cotton-tipped applicator with normal saline solution or sterile water. Place applicator tip in deepest
aspect of the wound and measure distance to the skin level.
4. The wound care nurse is notified of all hospital-acquired pressure injuries/ulcers.
5. When any of the following conditions has been document a Wound Care (WOCN) consult will be
generated. The physician should be notified for pressure injuries/ulcers to assist with treatment guidelines.
· Stage 3
· Stage 4
· Unstageable
· Deep Tissue Pressure Injury
· Pressure injury noted on admission
· Hospital- Acquired pressure injuries (HAPI) treatment guidelines as necessary.
However, that was not done.