HospitalInspections.org

Based on policy review, record review, document review and interview, the hospital failed to ensure staff promoted and acted upon each Patient's Rights for 1 (Patient 3, P3) of 10 patients reviewed. This deficient practice has the potential to place patients at risk for dissatisfaction in the care they receive and poor outcomes.

Findings Include:

1. The hospital failed to ensure the "Complaint/Grievance: Management of Patient and Family," policy included the definition of a grievance as defined in the federal regulations. (Refer to tag A-0118)

2. The hospital failed to ensure a patient's grievance response letter included the name of the hospital contact person and the results of the grievance process. (Refer to tag A-0123)

3. The hospital failed to ensure staff assessed pain and implemented an individualized pain management and comfort care plan. (Refer to tag A-0130)

Based on policy review and interview, the hospital failed to ensure the "Complaint/Grievance: Management of Patient and Family," policy included the definition of a grievance as defined in the federal regulations. This deficient practice has the potential to affect the current eight inpatients and any future patient admitted to the hospital.


Findings Include:


Review of the policy titled "Complaint/Grievance: Management of Patient and Family," dated 03/29/19, indicated patient grievance was defined as ". . . Patient Grievance - A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved before discharge) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issue related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (COP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Statute 489. Patient Complaint - A verbal patient care complaint that can be resolved prior to discharge. Post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance. Billing Issues - Billing issues are not usually considered grievances. However, a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Statute 489 are considered a grievance. . ."


The policy failed to identify a grievance as a written or verbal complaint that is not resolved at the time of the complaint by staff present as defined in the federal regulation.


During an interview on 11/14/22 at 2:05 PM, Director of Compliance, Risk, and Quality (DCRQ) confirmed the hospital's definition of a grievance did not meet the definition of a grievance as written in the federal regulations. DCRQ stated the hospital's practice is to consider a complaint a grievance if it cannot be resolved prior to discharge.

Based on policy review, document reviews, and interview, the hospital failed to ensure a patient's grievance response letter included the name of the hospital contact person and the results of the grievance process for one of one patient (Patient (P)3) grievance reviewed. This deficient practice had the potential to affect the current eight inpatients and any future patient admitted to the hospital.


Findings Include:


Review of the policy titled, "Complaint/Grievance: Management of Patient and Family," dated 03/29/19, indicated ". . . Procedure: . . . F. An initial follow-up response will occur with the individual lodging the grievance, generally within forty-eight (48) hours. Upon completion of the investigation, the Quality Manager or designee will provide the individual with a written notice which contains the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. G. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative, that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within 14 days. . ."

Review of the "Patient Grievance Log 2022" dated 07/01/22 to 11/14/22 showed the hospital had received one grievance during this time period. The review indicated the grievance was submitted by P3.

Review of a grievance investigation for P3 indicated the date of the grievance was 07/11/22 at 10:00 AM and the department involved was surgical services. Review of the grievance documented by reviewer DCRQ indicated "[P3] reports being dissatisfied with being asked to arrive 2 hours prior to procedure taking place. States [his/her] BP [blood pressure] was the most painful BP cuff [he/she] has ever used. Also reports bed was painful and does not feel pain was managed ...

Review of the grievance indicated DCRQ documented the grievance was assigned 08/07/22 and completed 08/08/22.

Review of the documentation of the investigation showed the Investigation Findings showed ..."Follow UP: Grievance letter mailed 8/8/22 [08/08/22]."


Review of the grievance response letter dated 08/08/22, signed by DCRQ, and addressed to P3 indicated documentation did not include the name of the hospital contact person with contact information and the results of the grievance process.


During an interview on 11/14/22 at 2:05 PM, DCRQ stated he/she was not aware the letter needed to include a contact number and specifically address that DCRQ was the contact person. DCRQ stated DCRQ thought that by signing the response letter, P3 would know that DCRQ was the contact person. DCRQ confirmed he/she did not address one of the concerns (time the procedure was scheduled) expressed by P3 in the response letter.

Based on record review, document review, and interview, the hospital failed to ensure staff assessed pain and implemented an individualized pain management and comfort care plan for one of 10 patients (Patient (P)3) who received colonoscopies (an exam used to look for changes such as polyps or cancer in the large intestine and rectum) during the period 07/01/2022-11/14/2022. Failure to address a patient's comfort and pain needs can lead to an increased level of discomfort which can negatively impact on the patient's overall health status.


Findings Include:


Review of the hospital policy titled, "Patient Rights and Responsibilities," dated August 2019, revealed, "The patient has the right to appropriate assessment and management of pain. The hospital plans, supports, and coordinates activities and resources to assure the patient's pain is recognized and addressed appropriately. This includes initial assessment and regular reassessment of pain."


Review of the hospital policy titled, "Pain Management," dated October 2021, stated, "Should the patient express the presence of pain, then a comprehensive pain assessment will be completed using the following criteria:
1. Location of pain
2. Intensity of pain, using a 0-10 pain scale . . .
3. Quality of pain, using the descriptive words of the patient"

The policy defined reassessment of pain following medication intervention as " ...at a minimum of thirty (30) minutes for IV and one (1) hour for oral medications . . ."


Review of P3's closed record revealed that the patient was scheduled to arrive at the hospital for an outpatient colonoscopy at 8:00 AM on 07/11/22. Review of P3's Preop Nursing Record" indicated that P3 arrived in pre-op (a holding area until patient is transferred to a procedure or operating room) at 7:43 AM and was ready for the procedure at 10:05 AM. Review of the Nursing Record" indicated that P3 entered the operating room (OR) at 11:37 AM and P3 was out of the OR at 12:12 PM. Review of the PACU (Post Anesthesia Care Unit) "Nursing Record Summary" indicated that P3 was discharged at "1300" (1:00 PM).

Review of P3's record indicated that the length of time in the bed before being transferred to the OR was approximately three hours and 54 minutes.

Review of the "Care Plan Note" for P3, under the "Nursing Documentation" tab, showed areas of patient concerns that the staff would need to monitor for any patient receiving a colonoscopy included: "Pain Related to Procedure," ...

Review of the "Medication Administration Record" (MAR) showed that P3, received 50 mcg of fentanyl intravenous (IV) push (pushing medication directly into the bloodstream with a syringe into the IV line) at 10:16 AM. There was no indication in P3's record as to why the medication was given or any assessment or reassessment of P3's condition that warranted pain medication.

During an interview on 11/14/22 at 1:45 PM, Registered Nurse (RN)2, who was assigned to P3 on the day of the colonoscopy, stated P3 reported a pain score of zero when asked during his/her assessment. After looking at the patient's record, RN2 stated that he/she had completed the assessment at 8:24 AM on the morning of 07/11/22. RN2 stated he/she looked in on P3 by pulling back the privacy curtain, several times over the next hour to hour and a half and the patient seemed to be resting with eyes closed. At around 10:00 AM, RN2 stated that the patient's wife came out of the bay area and stated that P3 was in pain and needed something. RN2 asked a physician who was close by (could not remember which one) if he/she could give P3 something for pain and received an order for 50 micrograms (mcg) of fentanyl (a powerful synthetic opioid analgesic similar to morphine but much more potent). RN2 confirmed that he/she could not find documentation in the record that he/she had assessed P3's pain, talked with the patient about the pain or location of the pain, or reassessed the effectiveness of the medication. RN2 stated he/she did not assess the patient but took the wife's word that P3 was in pain. RN2 stated that he/she should have assessed P3 for pain and should have reassessed his/her level of pain and the effectiveness of the fentanyl.

During a telephone interview on 11/14/22 at 4:15 PM, P3 stated that the fentanyl lasted only a short while and that he/she was in so much pain that he/she thought about leaving and going home. P3 reported that he/she is 6 feet 4 inches and weighs 419 pounds, making the bed very uncomfortable to stay on for any length of time.

During an interview on 11/15/22 at 12:35 PM, RN2 and RN3 when asked if either had added to the care plans with anything other than the standard concerns, they indicated that they had not. When asked if they had considered adding a treatment plan that would focus on patient comfort or pain prior to the procedure, RN2 stated that they could add areas of concern but indicated that it was not a common practice. When asked about P3 with morbid obesity and the need for comfort measures and pain meds, both stated that P3 had received something for pain, but the care plan did not speak to the morbid obesity and did not change after pain medication was given. The Chief Nursing Officer (CNO) who was sitting in on the interview stated that they are still adjusting to the new electronic medical record system and trying to determine what all the system can do.