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Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to promote the rights of Patients #1, #2, #3, #4, #5, #6, #7, #8, eight (8) of (8) patients reviewed.

Findings include:


On 4/12/17 the State Office Complaint Hotline received a complaint which stated:
"I am making a complaint against the hospital (Emergency Department) because I feel I was neglected by not receiving pain medication during my visit or an ice pack to relieve the pain. I feel I was not discharged correctly and was still in pain when discharged."


An unannounced visit was made to the facility on 5/10/17. During an interview on 5/10/17 at 9:30 a.m. the Hospital Administrator and the Director of Quality confirmed they were aware of the complaint.


Review of the facility's documentation regarding Patient #1's complaint revealed that Patient #1 called the hospital on 1/24/17 at 9:38 a.m. and complained of being treated unfairly by the nursing staff. He stated that he felt the nursing staff did not take his symptoms seriously. The complaint was turned over to the Director of Emergency Department (ED). Review of the documentation from the Director of ED revealed Patient #1 did not feel he was clinically treated the way he thought he should. He stated he wanted crutches. The Director of ED stated to this patient the reason the health care provider did not order crutches was because of his Parkinson's disease, that the provider felt it was unsafe for him to use the crutches.


An interview with the Director of Emergency Department (ED) on 5/10/17 at 11:00 a.m. revealed that she had called Patient #1 to confirmed the complaint. She stated he also complained he wanted crutches and she explained to him that with his diagnosis of Parkinson's the Health Care Provider felt it was unsafe to use crutches. She stated he also wanted a wheelchair and she told him she would get it ordered for him. The Director of ED stated that Patient #1 agreed to come the next day to pick up the order, but he never showed up. She also stated that when she spoke with him on the phone he was fine and satisfied with the outcome. When asked if he was instructed on how to file a grievance/complaint or instructed in writing she stated, "No."

During an interview on 5/10/17 at 11:20 a.m. the ED Nurse Practitioner (NP) stated, "Normally I don't give a first dose of pain medicine in the ED, unless they truly need it or it's after hours and the Pharmacy is closed." When asked if a patient came in rating their pain as a "9" on a scale of 0 to 10, when would she routinely reassess their pain. The NP stated, "If I felt like they were really hurting and grimacing, I would give them something and reassess in 30 to 60 minutes. The patient's (Patient #1) tests revealed he did not have a tear in his Achilles tendon and there were no broken bones. I prescribed Ibuprofen for him."


During an interview on 5/10/17 at 11:48 a.m. the ED Registered Nurse (RN) was asked when would she routinely reassess a patient's pain if that patient come in rating their pain level between an eight (8) and 10 on a scale of 0 to 10. She stated, "I would go back within 10 to 15 minutes and ask if their pain was still between an 8 and a 10."


During an interview on 5/10/17 at 1:36 p.m. the Emergency Department Director was asked if there was anywhere else in the patient's medical record where a pain reassessment might be documented. She stated, "Probably not." The Director was asked what the Triage Nurse would normally asked a patient related to pain. She stated, "She should ask if the patient was in pain, where their pain was, and on a scale of 0 to 10, what would they rate their pain." She also stated, "Pain should be reassessed every shift and after pain medication is given, but if the physician makes the assessment that the patient doesn't need pain medication then it would probably not be reassessed." The Director stated that the facility did not have a Policy for Triage Nurse Assessment.


Record review revealed Patients #1, #2, #3, #4, #5, #6, #7, #8 all presented into the Emergency Department complaining of pain. Four (4) of the patients were not assessed for pain although they complained of pain. Four (4) of the patients were rated on a pain scale as a 9 or 10 (on a 0-10 scale). There was no documented evidence that their pain was ever re-assessed. Record review revealed Patients #1, #2, #3, #4, #5, #6, #7, #8 did not receive a notice of their rights.

During an interview on 5/10/17 at 12:30 p.m. the Director of Quality reviewed the eight (8) patient charts and confirmed that some of the patients were not re-assessed for pain, some were missing pain assessments, and none of the eight (8) patients had documentation of the patients receiving their notice of rights..

Review of the facility's "Pain Management Standard of Care" policy (Revision Date: 2/1/13) revealed, "Policy-All patients will be appropriately assessed and re-assed for pain and interventions will be conducted in a timely manner to provide pain relief. The patient will exhibit adequate pain management as evidenced by verbal description, pain scale, and assessment." ..."Procedure-All patients will be assessed for presence and history of pain. Upon admission and during initial shift assessments, the staff will assess the patient for pain. Page 5-"Documentation-Pain assessment and appropriate interventions will be documented as indicated in the electronic medical record."


Review of the facility's "Standards of Nursing Practice" policy (Revision Date: 12/2013) revealed, "Policy- ....nurses will evaluate the quality of care based on the following standards of nursing care." "Standard I-Critera: An initial assessment includes ...Wong-Baker Pain Scale, FLACC Pain Rating Scale ...This data is used to determine the nursing needs of the patient..."


Review of the facility's "Patient Complaint and Grievance Process" policy (Revision Date: 2/28/14) revealed, "Grievance-A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient ...A complaint involving or alleging a violation of a patient's rights, abuse, neglect, harm ...or regulatory violations ...", "Addressing and Resolving Complaints: Complaints, investigations results, actions taken and follow-up documentation should be forwarded to the Quality Department for review ...a prompt written response within 7 days if possible..All grievances are followed-up in writing ...All grievance response letters will be mailed to the patient's home address ..."


Review of the facility's "Registration Checklist of Information" Policy, (Revision Date: 2/2016) revealed, "Policy-It is the Policy to appropriately communicate with patients as required by regulatory agencies and to improve patient safety at the point of registration by providing ..."Registration Checklist-Rights and responsibilities and Concerns"

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to appropriately notify Patients #1, #2, #3, #4, #5, #6, #7, #8, eight (8) of (8) patients reviewed, of their rights.


Findings include:


Cross Refer to A0115 for the facilities failure to ensure the notice of rights requirements were met for Patients #1, #2, #3, #4, #5, #6, #7, #8.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to inform Patients #1, #2, #3, #4, #5, #6, #7, #8 (eight (8) of eight (8) patients) reviewed of their right(s) in advance of care performed.


Findings include:


Cross Refer to A0115 for the facilities failure to inform Patients #1, #2, #3, #4, #5, #6, #7, #8 of their rights before providing care.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to establish a process for complaint resolution and failed to inform Patient #1 how to file a grievance.

Findings include:


Cross Refer to A0115 for the facilities failure to provide a prompt resolution of a grievance and failure to follow their own policy of grievance by informing Patient #1 how to file a greivance.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to establish a clearly explained procedure for submission of written or verbal grievances.


Findings include:


Cross Refer to A0115 for the facilities failure to clearly explain to Patient #1 the grievance procedure.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to notify Patient #1 a response to his grievance in writing.

Findings include:


Cross Refer to A0115 for the facilities failure to follow their own policy and notify Patient #1 in writing of their actions to his complaint.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to provide written notice of its decision and the results of the grievance process and the date of completion to Patient #1.


Findings include:


Cross Refer to A0115 for the facilities failure to provide written notice of its decision or results regarding his greivance to Patient #1.

Based on document review, staff interview, and policy and procedure review, the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program, that reflects the complexity of the hospital's organization and services; involves all hospital departments and services; and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.



Findings include:



Review of the facility's "Hospital Quality Dashboard" and "Emergency Department Statistics" revealed there was no documented evidence of an effective Performance Improvement Program.


During an interview on 5/10/17 at 3:58 p.m. the Director of Quality Assurance (DQA) stated, "There aren't any chart audits being done at this time, and I don't find any evidence that Performance Improvement is being done related to patient care in the Emergency Department (ED)"


Review of the facility's "Performance Improvement Plan", effective 1/1/14 and last revised 1/15/16, revealed "Scope- Facility-wide, Purpose-The goal of the Performance Improvement (PI) Plan is to identify (the facility's) approach to improving processes through prioritization, design, implementation, monitoring and analysis of performance initiatives and assure that activity results in accomplishment ...The process for identifying PI initiatives is to first identify strategic goals ...These strategic goals, also with regulatory requirements, opportunities identified in external benchmark projects, opportunities identified through analysis of occurrence reports and existing process monitoring are evaluated and prioritized annually by hospital leadership, with a focus on those that are high risk, high volume, low volume/high risk, or have a history of being problematic. Model-(The facility) advocates the use of the "Plan, Do, Check, Act" method (Deming Cycle) as outlined below: ...Plan-to improve processes first by finding out what things are going wrong (that is, identify the problems faced), analyzing the current situation, identifying root causes, and generating solutions ..."

Based on document review, staff interview, and policy and procedure review, the facility
1. failed to maintain a Quality Assessment and Performance Improvement (QAPI) Program which includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and failed to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations. incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization; and
2. failed to use the data collected to monitor the effectiveness and safety of services and quality of care.


Findings include:


Cross Refer to A0263 for the facility's failure to maintain a QAPI Program which includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and failed to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations and failed to incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization, and failed to use the data collected to monitor the effectiveness and safety of services and quality of care.

Based on document review, staff interview, and policy and procedure review, the facility failed to set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care.

Findings include:

Cross Refer to A0263 for the facility's failure to set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care.

Based on document review, staff interview, and policy and procedure review, the facility failed to conduct performance improvement projects as part of its quality assessment and performance improvement program.


Findings include:


Cross Refer to A0263 for the facility's failure to conduct performance improvement projects as part of its quality assessment and performance improvement program.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to have a Registered Nurse (RN) supervise and evaluate the nursing care for Patients #1, #2, #3, #4, #5, #6, #7, #8, eight (8) of (8) patients reviewed.


Findings include:


Cross Refer to A0115 for the facility's failure to have a RN supervise and evaluate the nursing care for Patients #1, #2, #3, #4, #5, #6, #7, #8.

Based on medical record review, complaint review, facility complaint documentation review, staff interview, and policy review, the facility failed to ensure that the nursing staff develops and keeps current, a nursing care plan for each patient.

Findings include:

Cross Refer to A0115 for the facility's failure to assess and/or reassess Patient #1, #2, #3, #4, #5, #6, #7, & #8 while in the Emergency Department.