HospitalInspections.org

Based on document/record review and staff interview, it was determined for one of one patients (Pt #1) the hospital failed to ensure complaints alleging abuse followed the grievance process policy.
Findings include:

A. The policy "Patient Complaints and Grievances," last revised 7/13, was reviewed 12/3/13 at 9:45 AM. It stated a grievance is defined as "a formal or informal written or verbal complaint that is made to the hospital by a patient or patient's representative, regarding the patient's care, abuse or neglect...the grievance committee shall be responsible for reviewing and referring formal grievances for internal investigation...complaint cannot be resolved at time of the complaint by staff present...the complaint is a grievance..."

Pt#1's medical records for admissions 4/20/13 thru 5/8/13, 7/19/13 thru 7/23/13 and 9/8/13 thru 9/19/13 were reviewed 12/3/13.

B. Admission 4/20/13 with a diagnoses of pneumonia, end-stage Parkinson disease, dysphagia with a gastrostomy/jejunostomy (G-J) tube, dementia, decubitus ulcers over left and right foot, left knee and left and right hands and seizure disorder. On 5/2/13 Pt #1's admission status was changed to palliative/hospice care. On 5/5/13 the hospice services were revoked per family's request for treatment of right arm swelling and pain. An x-ray on 5/6/13 of the right shoulder was interpreted as an acute comminuted, impacted, displaced proximal right humerus fracture. The Hospitalist Progress note dated 5/7/13 stated the "family concerned that fracture may have occurred during some manipulation of the patient...10 days ago close to Wednesday the 24 th..." The Patient Relations Report #PR-10399 created 5/8/13 by the Patient Advocate (E19) stated Pt#1s spouse was put in contact with the advocate office by the cashiers office. The spouse related Pt #1 had suffered a broken arm while hospitalized, was being discharged and required pain medication for the broken arm and could not pay for them. The report stated the spouse was tearful and stated no one could explain how the break occurred. E19 notified the Lead RN (Registered Nurse) to have the Nurse Manager to go talk to the spouse when the Nurse Manager returned. The report listed the nature of the event was "Injury/Safety..."and classified the "Final Event" as a "Category E: Temporary harm to the patient/person and required intervention." The case was closed by E19 on 5/8/13 and referred to E4 (Risk Manager).

C. Admission 7/19/13 with a diagnoses of sacral decubitus ulcer, bilateral heel ulcers and recurrent aspiration pneumonia. The Nursing Daily Assessment report dated 7/19/13 at 11:01 PM under "situation/response" section stated family was overheard by the security guard stating that nursing staff physically grabbed her/him by the arm and shoved..out of the room." An unnumbered Patient Relations Report created 7/19/13 at 11:46 PM by the third shift Nurse Supervisor (E29) stated family was upset with how staff grabbed Pt #1's broken arm during transfer to the bed. A family member was overheard alleging staff grabbed the family members arm. A note dated 7/20/13 at 8:11 PM stated "On previous admission...blaming nursing care on right arm fracture...threatening to sue...security guard overheard...stating that nursing staff physically grabbed her/him by the arm and shoved ...out of the room..." The report listed the nature of the event was "Injury/Safety..."and classified the "Final Event" as a "Category E: Temporary harm to the patient/person and required intervention." The case was closed by E4 on 7/20/13. The Nurse Manager (E11) was interviewed on 12/5/13 at 1:45 PM. E11 stated it was confirmed by employee admission that a Registered Nurse (E32) physically grabbed a family member and was terminated for the action.

D. Admission 9/8/13 for sepsis with septic shock secondary to urinary tract infection, pneumonia and an infected sacral decubitus ulcer. A Care Conference note dated 9/18/13 at 11:15 AM stated "family is concerned for fracture..." The Patient Relations Report #PR-10740 created 9/19/13 stated during a care conference on 9/18/13 the family expressed that staff caused the broken arm by turning patient with hands placed on right shoulder. An entry by E19 entry on 9/20/13 at 9:31 AM stated family "says now... shoulder is dislocated because of "abuse" by staff....suspects other patients are being "abused"..." The report listed the area of concern as "Care Issues" and was closed by E19 on 9/20/13.

E. E19 was interviewed 12/4/13 at 9:15 AM. E19 stated the Patient Advocates role is to coordinate the appropriate people to assure resolution of a complaint. E19 stated the Patient Advocates, Department Managers and sometimes the Patient Safety Officer are responsible for deciding if the complaint is a grievance or not.

F. E4 was interviewed 12/4/13 at 9:15 AM. E4 stated if a complaint is identified as a patient safety issue, E4 is notified to investigate and makes the decision if the complaint should follow the grievance process. E4 stated the events reported in May, July and September of 2013 were considered complaints, no letters were sent to family and the complaint/grievance committee was not notified.

G. The Chief Nursing Officer (E2) was interviewed 12/4/13 at 3:00 PM. E2 reviewed Pt#1's medical record , the Patient Relations reports and stated as abuse was alleged by the family, the complaint should have been treated as a grievance and brought through the Complaint/Grievance Committee, Patient Safety Committee and Clinical Council.

Based on document/record review and staff interview, it was determined for one of one patients (Pt #1) the hospital failed to protect patient safety by ensuring concerns, complaints and grievances are thoroughly investigated, reviewed, tracked and resolved.
Findings include:

1. The policy "Patient Complaints and Grievances" last revised 7/13 was reviewed 12/3/13 at 9:45 AM. It stated the purpose of the policy was to improve the delivery of quality healthcare services and protect patient health and safety by ensuring that their concerns, complaints and grievances are reviewed/investigated, tracked and resolved...the grievance committee shall be responsible for reviewing and referring formal grievances for internal investigation..."

2. The medical record of Pt #1 was reviewed 12/ 3/13 at 2:00 PM. Pt #1 was admitted on 4/20/13 with the diagnoses of Pneumonia, end-stage Parkinson's Disease, dysphagia (G-J tube), dementia, decubitus ulcers over left and right foot, left knee and left and right hands and seizure disorder. Nursing Daily Assessment documentation stated on 5/4/13 at 10:32 PM " Family concerned about swelling in patients right shoulder ...refusing turns because of pain ..." On 5/6/13 hospice services were discontinued due to family concerns for right shoulder pain and a right shoulder x ray was completed at 9:57 AM. On 5/6/13 at 10:22 AM a Consultation Report by the orthopedic surgeon (E27) stated an impacted and somewhat comminuted fracture of the right femoral neck with questionable etiology and when compared to the 4/29/13 chest x-ray the right humerus was seen as intact. The Hospitalist's Progress Note dated 5/6/13 stated " X-ray shoulder/chest reviewed. Discussed findings with patient ' s family. Fracture appeared to have taken place in the last few days ... Date indeterminate. Will ask nursing supervisor/floor manager to follow protocol and investigate where and how if possible, patient sustained injury/fracture. Swelling 1st documented on 5/2/13 by nursing however per family it has been there for a few more days."; 5/7/13 progress note stated " Patient ' s family concerned that fracture may have occurred during some bedside manipulation of patient while cleaning linen 10 days ago close to Wednesday the 24th while they had an issue with an aide who was working with patient. However per chest x-ray done 4/29/13 there does not appear to be a fracture seen on the film indicating the fracture occurred later than the 29th."

3. The Patient Relations complaint tracking database (Peminic) report dated 5/8/13 was reviewed with the Patient Advocate (E19) and the Risk Manager (E4) 12/4/13 at 9:15 AM. The report (PR-10399) created 5/8/13 by E19 stated the spouse of Pt #1 was put in contact with the advocate office by the cashiers office. The spouse related that Pt #1 had suffered a broken arm while hospitalized, was being discharged and required pain medication for the broken arm and could not pay for them. The report stated the spouse was tearful and stated no one could explain how the break occurred. E19 notified the Lead RN (Registered Nurse) to have the Nurse Manager to go talk to the spouse when the Nurse Manager returned. The report listed the nature of the event was "Injury/Safety..."and classified the "Final Event" as a "Category E: Temporary harm to the patient/person and required intervention." The case was closed by E19 on 5/8/13 and referred to E4.

4. An interview with E4 on 12/4/13 at 9:15 AM was conducted. E4 stated the complaint was not considered a grievance because the arm fracture of Pt #1 was a result of a seizure or possibly pathological in nature. E4 stated the decision to make a complaint a grievance or not, is made by E4. E4 stated each complaint was resolved, therefore complaints were not tracked or trended as problematic and not taken to the Complaint/Grievance Committee, Patient Safety Steering Committee or Clinical Council (Quality) for review. E4 stated Pt #1's bill was adjusted to compensate the family's request.

5. An interview with the Chief Nursing Officer (E2) 12/4/13 at 3:00 PM was conducted. E2 reviewed the the medical record of Pt #1, the Peminic reports and stated the etiology of Pt #1's broken arm was not confirmed to be caused by a seizure or pathologic in nature. The complaint should have treated as a grievance and a thorough investigation should have been brought through the Complaint/Grievance Committee, Patient Safety Committee and Clinical Council for monitoring.

Based on document review and interview, it was determined for 1 of 1 patients (Pt #1) the Hospital failed to report and conduct a thorough investigation of an allegation of patient harm caused by staff.
Findings include:

1. The "Patient Safety Plan," revised 9/13, was reviewed 12/3/13 at 2:30 PM. It stated "leadership...is responsible for establishing processes for the identification, reporting, analysis and prevention of sentinel/never events... an evaluation of patient...visitors..events...occurrence information from aggregated data reports and individual incident occurrence reports will be reviewed... Peminic classification events A through I... shall be forwarded to the Patient Safety Steering Committee, Clinical Council, the Board of Directors and other venues deemed appropriate"

2. The medical record of Pt #1 was reviewed 12/ 3/13 at 2:00 PM. Pt #1 was admitted on 4/20/13 with the diagnoses of Pneumonia, end-stage Parkinson's Disease, dysphagia (G-J tube), dementia, decubitus ulcers over left and right foot, left knee and left and right hands and seizure disorder. Nursing Daily Assessment documentation stated on 5/4/13 at 10:32 PM " Family concerned about swelling in patients right shoulder ...refusing turns because of pain ..." On 5/6/13 hospice services were discontinued due to family concerns for right shoulder pain and a right shoulder x ray was completed at 9:57 AM. On 5/6/13 at 10:22 AM a Consultation Report by the orthopedic surgeon (E27) stated an impacted and somewhat comminuted fracture of the right femoral neck with questionable etiology and when compared to the 4/29/13 chest x-ray the right humerus was seen as intact. The Hospitalist ' s Progress Note dated 5/6/13 stated " X-ray shoulder/chest reviewed. Discussed findings with patient ' s family. Fracture appeared to have taken place in the last few days ... Date indeterminate. Will ask nursing supervisor/floor manager to follow protocol and investigate where and how if possible, patient sustained injury/fracture. Swelling 1st documented on 5/2/13 by nursing however per family it has been there for a few more days. "; 5/7/13 progress note stated " Patient ' s family concerned that fracture may have occurred during some bedside manipulation of patient while cleaning linen 10 days ago close to Wednesday the 24 th while they had an issue with an aide who was working with patient. However per chest x-ray done 4/29/13 there does not appear to be a fracture seen on the film indicating the fracture occurred later than the 29 th. On the 30 th patient had a seizure which may have been probable cause. However, it cannot be said with surety " ; 5/7/13 at 10:24 AM Hospitalist Progress Note stated " likely ? pathologic." There was no documentation the etiology or time of incident was ever identified.

3. Patient Relations- Peminic (complaint tracking database) report dated 5/8/13 was reviewed with the Patient Advocate (E19) and the Risk Manager (E4) 12/4/13 at 9:15 AM. The Peminic report (PR-10399) created 5/8/13 by E19 stated the spouse of Pt #1 was put in contact with the advocate office by the cashiers office. The spouse related that Pt #1 had suffered a broken arm while hospitalized, was being discharged and required pain medication for the broken arm and could not pay for them. The report stated the spouse was tearful and stated no one could explain how the break occurred. The report listed the nature of the event was "Injury/Safety..."and classified the "Final Event" as a "Category E: Temporary harm to the patient/person and required intervention." The case was closed by E19 on 5/8/13 and referred to the E4.

4. An interview with E4 on 12/4/13 at 9:15 AM was conducted. E4 stated Pt #1's arm fracture acquired during the admission date 4/20/13 thru 5/8/13 was not reported or investigated as a hospital acquired occurrence because the arm fracture was "not the staff's fault. It was the result of a seizure or was pathologic in nature." E4 stated each event was resolved and events were not tracked or trended as problematic; therefore, events were not taken through the Patient Safety Steering Committee or Clinical Council (Quality). E4 stated Pt #1's bill was adjusted to compensate the family's request.

5. An interview with the Chief Nursing Officer (E2) 12/4/13 at 3:00 PM was conducted. E2 reviewed the the medical record of Pt #1, the Peminic reports and stated this event should have had a Root Cause Analysis performed and brought through the Clinical Council.