HospitalInspections.org

Based on review of Policy, Procedure, clinical record review, hospital grievance/complaint log and interview with hospital staff the hospital failed to inform each patient whom to contact to file a grievance.

Findings include:

Review of hospital Policy: "Patient Complaint Resolution; Policy # 1000.38 revealed the following: Objective: Receipt of any patient complaint is viewed as an opportunity to learn how our services are perceived and how those services may be improved. The objectives of this policy are:
1. To encourage staff to resolve all patient complaints quickly at the point of service.
2. To provide prompt acknowledgement and communicate resolutions for each customer complaint as soon as possible.
3. To assure that any person with a complaint is provided an equitable and timely review process.
4. To provide a process for patients or the patient's representative to file a formal grievance and receive feedback.
5. To identify trends in customer complaints which can be analyzed to find opportunities to improve customer relations.
6. To ensure compliance with applicable regulations and accrediting bodies.
Complaint Management: 1. Management of complaints is best accomplished at the point of service. Any employee or physician receiving a verbal complaint will acknowledge the complaint promptly, and attempt to resolve those that fall within his or her level of responsibility. The department/unit manager will be informed of the complaint as indicated and as needed to resolve the complaint. Patient Relations can coordinate complaints involving multiple departments.
2. When department/unit manager, his or her designee, or Patient Relations is unavailable, the nursing supervisor should be contacted if caller, patient, or visitor requests to speak with someone immediately if situation warrants prompt intervention.
3. After having been notified of the complaint, the department/unit manager, or their designee, will contact the patient and/or family member to review the concern and bring resolution.

Access report listing all activity concern received 02/01/2010 - 04/30/2010 (noted as "not specific to grievances, as the DB (database) will not query on that field") lacked documentation of any activity related to complaint OR#00005881.

Reviewed ten (10) clinical records (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10); one of ten (P2) revealed the lack of documentation of complaint, incident report or notification to family of patient's fall on 04/08/2010.

Additional findings in clinical record for P2:
Post op orders include: Activity: bed rest x18 hours, then ad lib; Body Mechanics/Precaution - Lumbar - No bending, lifting, twisting. Log roll, pillow between knees in side-lying position. Trapeze PRN to assist with mobility. Patient is not to sit in chair >30 minutes.
Medications: Pain Management IV: Hydromorphone (Dilaudid) 0.2 - 0.6 mg IV every 30 minutes prn moderate to severe breakthrough pain or while NPO (nothing by mouth). Pain Management - Routine PO: Morphine ER (MS Contin) 15mg PO every 8 hours routinely. Pain Management - PRN PO: Oxycodone (Roxicodone) 5 - 10 mg PO every 3 hours prn moderate pain.
Other Medications: (included but not limited to) Diazepam (Valium) 1.25 - 2.5mg IV every 4 hours prn muscle spasm - (DC when taking po); Insulin Scale --- See Preprinted Orders; Medications when taking PO: Tizanidine (Zanaflex) 4mg po every 6 hours prn muscle spasms.

Patient Assessment Summary and Progress Notes for 04/08/2010 lacked documentation of patient fall or notification to family.

Patient Assessment Summary dated April 9, 2010 at 1240 notes: "limited ROM (range of motion) to left hip d/t (due to) prior surgeries and yesterday's fall agitated it".

Progress note dated 04/09/10 (date overwritten to 04/08/10) at 1830, titled "Nsg Addendum" documents the following: "While assisting pt in Rm 347, I heard my name called loudly from room 345. Immediately went to Rm 345 to find pt laying on his back on the floor, half in and half out of the bathroom. I asked the pt if he fell and he stated NO! He said the CHT (certified health technician) Hadley has assisted him to bathroom and left him sitting on the toilet. He felt that he was strong enough to stand when finished and tried to stand up, but his L (left) leg gave out and he grab the grab bar and lowered himself to the floor. Unable lift pt by myself.....Pt again stated his L leg gave out while trying to stand and he was again reminded not to try to stand without help. Patient also stated that L hip pain continued as before. K pad reapplied to the area".

Hospital grievance/concern log filed between February 1, 2010 and April 30, 2010 lacked documentation of complaint/incident related to patient P2.

Discussed with E1 on 06/10/2010 at 1300.

E1 later reported he/she had confirmed with hospital Risk Management office that no incident/complaint related to patient P2 had been received by that office.

Findings discussed with E1 and E2 on 06/10/2010 at 1500.

Based on review of Policy, Procedure, clinical record review, and interview with hospital staff the hospital failed to inform the patient or his/her representative of patient health status, involve patient or patient representative in care planning and treatment, and being able to request or refuse treatment.

Findings include:

Review of hospital Policy: "Patient and Visitor Incidents: Definitions, Reporting and Management of Incidents, and Reviewable/Reportable Events; Policy #LHS.100.28 states: Objective: To assure incidents inconsistent with the routine operations of the facility or care of a patient are reported and evaluated for improvement opportunities to ensure:
1. Prompt review and response to individual occurrences.
2. A through analysis when indicated.
3. Statistics derived from the collective numbers of incidents are aggregated to identify trends and implement risk prevention and quality improvement programs.
DEFINITIONS Incident - Any 1 event, which may involve: (a.) actual injury or potential injury to an individual or (b.) damage to hospital or clinic property. The definition of the term incident may but does not always reflect an error, breach in the standard of care or any system or process or adverse event. A patient's response to treatment in the absence of any error, breach in the standard of care or any system or process or adverse event may result in an incident."

Reviewed ten (10) clinical records (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10); one of ten (P2) revealed the lack of documentation of complaint, incident report or notification to family of patient's fall on 04/08/2010.

Patient Assessment Summary and Progress Notes for P2 dated 04/08/2010 lacked documentation of patient fall or notification to family.

Patient Assessment Summary dated April 9, 2010 at 1240 notes: "limited ROM (range of motion) to left hip d/t (due to) prior surgeries and yesterday's fall agitated it".

Discussed findings with E1 on 06/10/2010 at 1200, E1 was unable to find/produce documentation of incident or reviewable/reportable event for P2.

Findings discussed with E1 and E2 on 06/10/2010 at 1500.

Based on review of Policy, Procedure, clinical record review, and interview with hospital staff, the hospital failed to provide a safe setting.

Findings include:

Review of hospital Policy: "Standards of Care: Adult Inpatients; Policy # LHS.900.4001.Patient Care" states: "Patient Expectations: B. Promotion of a safe environment that maintains patient dignity and privacy, and incorporates emotional support; H. Involvement in care including transition planning and lifestyle changes; I. Support of the family-centered care model to meet psychosocial needs; J. Satisfaction with care as measured by verbal exchange, surveys, or other methods of communication.
Interventions: 1. Complete initial bio-psychosocial nursing assessment within approximately four (4) hours of admission and document findings. 4. Assess and document fall risk score on admission, transfer from another unit, after fall or with change in condition."

Policy "Standards of Care; Prevention of Falls and Fall related Injury; Policy #LHS.9000.4054.Patient Care" states: Patient/Family/Guardian Expectations: Care provided will assist the patient in meeting the following expectations: A. An individualized fall and fall injury prevention plan based on identified risk factors. B. Involvement in decision making, implementation and educational processes related to fall prevention. A. Interventions: The RN (registered nurse) coordinates the interdisciplinary plan of care and applies the nursing process: 1. FOR ALL PATIENTS: a) Identify patients upon admission who are at risk for injury related to falling by completing the Legacy Fall Risk Assessment Scale (LFRSAS) for all patients who are six years of age and older (Attachment #1). Potential risk factors for increase risk of falling include: 1) History of falls, 2) Impaired mobility and/or balance, 3) Impaired cognition, 4) Uncompensated sensory deficits (i.e. vision, hearing, touch), 5) Impaired toileting.
b) Reassess and document fall risk upon transfer to another unit, with any change in status or after a fall.

Reviewed ten (10) clinical records (P1, P2, P3, P4, P5, P6,P7, P8, P9, P10); one of ten (P2) revealed the lack of documentation of incident report or notification to family of patient's unwitnessed fall on 04/08/2010.

Documentation on Patient Assessment Summary, Form: Fall Risk Assessment Scale for P2 as noted below:
04/05/2010, Time: 2138; Fall risk assessment score = 9
04/06/2010, Time: 2341; Fall risk assessment score = 9
04/07/2010, Time: 2200; Fall risk assessment score = 5
04/08/2010, Time: 1920; Fall risk assessment score = 10 (change from prior assessment: 1 fall in past year)
04/09/2010, Time: 2030; Fall risk assessment score = 11 (change from prior assessments: requires 2-person assist)
04/10/2010, Time 2025: Fall risk assessment score =10

Patient Assessment Summary dated April 9, 2010 at 1240 notes: "limited ROM (range of motion) to left hip d/t (due to) prior surgeries and yesterday's fall agitated it".

Progress note dated 04/09/10 (date overwritten to 04/08/10) at 1830, titled "Nsg Addendum" documents the following: "While assisting pt in Rm 347, I heard my name called loudly from room 345. Immediately went to Rm 345 to find pt laying on his back on the floor, half in and half out of the bathroom. I asked the pt if he fell and he stated NO! He said the CHT (certified health technician) Hadley has assisted him to bathroom and left him sitting on the toilet. He felt that he was strong enough to stand when finished and tried to stand up, but his L (left) leg gave out and he grab the grab bar and lowered himself to the floor. Unable lift pt by myself.....Pt again stated his L leg gave out while trying to stand and he was again
reminded not to try to stand without help. Patient also stated that L hip pain continued as before. K pad reapplied to the area".

Findings were discussed with E1 and E2 on 06/10/2010 at 1500.

Based on review of Policy, Procedure, clinical records review, hospital grievance/complaint log and interview with hospital staff, the hospital failed to supervise and evaluate the nursing care for each patient.

Findings Include:

Reviewed Policy: "Standards of Care; Prevention of Falls and Fall related Injury; Policy #LHS.9000.4054.Patient Care" states: Patient/Family/Guardian Expectations: Care provided will assist the patient in meeting the following expectations: A. An individualized fall and fall injury prevention plan based on identified risk factors. B. Involvement in decision making, implementation and educational processes related to fall prevention. A. Interventions: The RN (registered nurse) coordinates the interdisciplinary plan of care and applies the nursing process: 1. FOR ALL PATIENTS: a) Identify patients upon admission who are at risk for injury related to falling by completing the Legacy Fall Risk Assessment Scale (LFRSAS) for all patients who are six years of age and older (Attachment #1). Potential risk factors for increase risk of falling include: 1) History of falls, 2) Impaired mobility and/or balance, 3) Impaired cognition, 4) Uncompensated sensory deficits (i.e. vision, hearing, touch), 5) Impaired toileting.
b) Reassess and document fall risk upon transfer to another unit, with any change in status or after a fall.

Reviewed ten (10) clinical records (P1, P2, P3, P4, P5, P6,P7, P8, P9, P10); one of ten (P2) revealed the patient was left in bathroom unattended which resulted in patient being found on bathroom floor.

Findings in medical record P2: 71 year old male admitted on 04/05/2010 at 0601 for scheduled surgical procedure (left L3-4 laminotomy/discectomy; L4-5 instrumented PLIF with allograft/PEEK); admitting diagnoses: left L3-4, L4-5 disc herniation and L4-5 spondylolisthesis; past medical history includes hypertension, hypothyroidism, diabetes mellitus type 11-NDDM, lumbar disc degeneration, lumbar HNP with myelopathy, lumbar spondylolisthesis - degenerative; past surgical history: knee replacement 3/08,
hip replacement: 9/08, 3/09; lumbar microdiscectomy L3-4, L4-5, 12/00. Medications: Glipizide 5mg, Metoprolol XL 200mg, Vicodin 5/500mg, Neurontin 300mg, Ambien 10 mg, Levoxyl, Oxybutynin, Omeprazole, Valium.

Per Pre-Anesthesia Questionnaire, patient height noted as 5'7", weight 115.4Kg; patient is noted to have neurologic problems (pain, numbness left low back and foot, wears a "lift" in left shoe to prevent foot drop; uses bilateral hearing aids.
Pre-Operative Note states: "His back pain is 8/10; his leg pain is 6-7/10. The midline back pain is described as aching. The pain radiates to the left lateral thigh and calf and is described as aching. There is decreased sensation in the left leg. He complains of weakness in the left foot....And ambulates with a cane."

Post op orders include: Activity: bed rest x18 hours, then ad lib; Body Mechanics/Precaution - Lumbar - No bending, lifting, twisting. Log roll, pillow between knees in side-lying position. Trapeze PRN to assist with mobility. Patient is not to sit in chair >30 minutes.
Medications: Pain Management IV: Hydromorphone (Dilaudid) 0.2 - 0.6 mg IV every 30 minutes prn moderate to severe breakthrough pain or while NPO (nothing by mouth). Pain Management - Routine PO: Morphine ER (MS Contin) 15mg PO every 8 hours routinely. Pain Management - PRN PO: Oxycodone (Roxicodone) 5 - 10 mg PO every 3 hours prn moderate pain.
Other Medications: (included but not limited to) Diazepam (Valium) 1.25 - 2.5mg IV every 4 hours prn muscle spasm - (DC when taking po); Insulin Scale --- See Preprinted Orders; Medications when taking PO: Tizanidine (Zanaflex) 4mg po every 6 hours prn muscle spasms.

Progress note dated 04/09/10 (date overwritten to 04/08/10) at 1830, titled "Nsg Addendum" documents the following: "While assisting pt in Rm 347, I heard my name called loudly from room 345. Immediately went to Rm 345 to find pt laying on his back on the floor, half in and half out of the bathroom. I asked the pt if he fell and he stated NO! He said the CHT (certified health technician) Hadley has assisted him to bathroom and left him sitting on the toilet. He felt that he was strong enough to stand when finished and tried to stand up, but his L (left) leg gave out and he grab the grab bar and lowered himself to the floor. Unable lift pt by myself.....Pt again stated his L leg gave out while trying to stand and he was again reminded not to try to stand without help. Patient also stated that L hip pain continued as before. K pad reapplied to the area".

Findings were discussed with E1 and E2 on 06/10/2010 at 1500.