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Based upon review of 1 of 6 medical records (#5), Grievances, Medical Staff Executive Committee Meeting Minutes, and staff interviews, the Governing Body failed to ensure an evaluation was conducted within a reasonable amount of time related to the quality of care provided to patient #5. Findings:

Review of the grievances revealed on 9/18/14 patient #5's wife filed a complaint with S4 RN/Risk Manager that identified patient #5 was at a hospital in Alexandria Louisiana and had to have his leg amputated because his wounds were neglected and not properly treated by the physician and nurses.

Interview with S4 RN/Risk Manager on 11/18/14 at 11:00 a.m. revealed she was responsible for the Grievance Process. Once a complaint was received, the complaint goes to the manager of that department for investigation. If the complaint is related to Physician Services, it would go to the Medical Staff for review of the physician's practice.

Review of the Medical Staff Executive Meeting Minutes revealed there failed to be evidence patient #5's medical record was reviewed by members of the Medical Staff related to the quality of care provided by S11 Physician.

Interview with S3 RHIT/QA Director on 11/18/14 at 1:00 p.m. revealed when complaints were received related physician quality of care issues, three members of the medical staff would review the complainant's medical record. When asked about quality of care issues identified by patient #5's wife and physician review of the medical record, S3 replied as of 11/20/14, no review had been conducted due to S21 Medical Director being out of the country so the review had been postponed (since the initial complaint was filed 9/18/14) until S21 had returned. There failed to be documented evidence any other member of the Medical Staff was appointed to conduct an investigation of the quality of care provided to patient #5 by S11 Physician.

Based upon review of the Grievance Logs, Grievances, 1 of 6 medical records (#5), and staff interviews, the hospital failed to ensure an adequate investigation was conducted of the complaint filed on 9/18/14 by patient #5's wife related to quality of care provided by the Physicians and Nurses. Findings:



Review of the Grievance Logs and the Grievances revealed on 9/18/14, patient #5's wife filed a grievance with the hospital related to the care and services provided to her husband while he was an in-patient from 8/13/14 to 9/2/14. According to the grievance, the wife alleged patient #5 had wounds to his legs that were not properly treated by the doctors or nurses, the nurses had his leg tied to an IV pole somehow to keep it elevated, he was not turned every two hours, and bathed with only using "wipes". Due to the neglect, her husband had to have an amputation of his right leg.

On 10/10/14, S4 RN forwarded patient #5's grievance to S7 RN/Medical/Surgical Supervisor for investigation. Review of S7 RN's investigation, dated 11/17/14 revealed:
"Regarding the bathing of the patient, I did explain that the wipes are all that can be used due to infection control requirements. I have reviewed the nurse charting and patient left Byrd to be transferred to (name of Rehabilitation Hospital) not LTAC (Long Term Acute Care). Wounds to legs were being treated with Silverdene per MD order, also nurses charted that MD was aware of wound changes. Multiple nurses documented that Clotramazole was applied to peri area per MD order for rash."
"Wound care orders were written on 8/18/14 and then different orders on 8/27/14"
"Pictures of patient's legs, buttocks and scrotum on chart. No turn schedules noted. After speaking with several nurses they all stated that he was able to turn himself and only needed assistance when getting out of bed."
"Multiple nurses did say that patient's leg was elevated using IV pole because (S11 Physician) was upset about the leg not being elevated high enough. Nurses state that MD was aware of leg being elevated this way."

Review of patient #5's medical record revealed the patient had contact dermatitis of the lower extremities due to compression stockings. When the patient removed the compression stockings at home, the skin had been weeping and partial skin from the right lower extremity was removed. Review of the initial photographs when the patient was admitted to the hospital, dated 8/13/14, revealed the left lower extremity had two black dots, one on the anterior and another to the medical area of the leg. The right lower extremity had erythema from below the knee to the toes with an area was dark red/black noted to the medial/posterior calf. There was no documentation by the nursing staff that described the stage of the wounds, the size, if there was any drainage, odor and the color.

Further review of the photographs revealed the next pictures in patient #5's medical record was dated 8/19/14 which showed the right lower extremity with a large blister that had popped leaving beefy red skin. There was no picture of the left lower extremity. On 8/24/14, no pictures were taken of the patient's bilateral lower extremities. On 8/31/14, photographs were taken of the left lower extremity which showed black areas on the back of the leg and open red/black areas of the anterior leg. Photographs of the right lower extremity showed large black areas on the posterior, medial, and anterior of the extremity. There failed to be documentation by the nursing staff of the stage, size, depth, presence or absence of drainage, odor and color.

Further review of patient #5's medical record revealed according to the nursing notes dated 9/1/14 revealed "Elevated leg has trouble staying in position on the pillow. Improvised an IV pole and folded sheet tied into a sling hung from the IV pole. Placed two ABD (Abdominal) pads on sling base, in contact with heel of foot. Foot elevated off bed successfully."

Interview with S4 RN/Risk Manager on 11/18/14 at 11:00 a.m. revealed she was responsible for the Grievance Process. Once a complaint was received, the complaint goes to the manager of that department for investigation. If the complaint is related to Physician Services, it would go to the Medical Staff for review of the physician's practice.

Interview with S3 RHIT/Quality Assurance Director on 11/18/14 at 11:30 a.m. revealed if the grievance is related to physician practice issues, the medical record would be reviewed by three physicians, then the results would be presented to the Medical Staff for review.

Even though S7 RN investigated the complaint submitted by patient #5's wife regarding care issues, there failed to be documented evidence the complaint was fully investigated in order to identify the missing documentation on the forms Photographic Wound Documentation related to the description of the wounds and the progression of the ulcers from erythema areas to the development of black eschar on the posterior, medial and anterior right extremity.

Based upon review of 1 of 6 medical records (#5), policies and procedures, and staff interviews, the hospital failed to ensure the Registered Nurse evaluated the nursing care for patient #5 as evidenced by failure of the nursing staff to follow the wound care policy and procedure related to: 1) obtaining weekly photographs of patient #5's lower extremity wounds, and 2) documentation of the description of the wounds on the "Photographic Wound Documentation" form. Findings:

Review of the nursing notes for patient #5 revealed the following documentation by the Intensive Care Nurses:
on 8/13/14 at 10:25 p.m. revealed "Received patient via stretcher, unable to transfer self, generalized weakness, drowsy but oriented...Right leg with 3+ pitting edema. Left leg with 2+ pitting edema, both legs have discoloration and open sores. Wife states sores are from removing compression stockings off at home. Pictures taken, see chart. Weak pedal pulses."

Review of the Photographic Wound Documentation form revealed the initial pictures taken of the patients bilateral lower extremities was dated 8/13/14. The right lower extremity picture showed redness from below the knee down to the foot. There was an area located on the posterior calf area in the shape of a square with dark red and black discoloration with an opened area in the middle. The left lower extremity pictured two small/pinpoint black discoloration to the anterior and medial calf. There failed to be documentation related to the stage, size, depth, presence or absence of drainage/type/tunneling, odor and color of the wounds.

Review of the Photographic Wound Documentation record dated 8/19/14 revealed a picture of the right lower extremity anterior region of a large blister that had burst; however, there failed to be a documented description related to the stage, size, depth, presence/absence of drainage/ odor and the color of the wounds. There was no picture of the left lower extremity.

Review of the Photographic Wound Documentation records dated 8/31/14 revealed large black eschar was pictured on the patients posterior and medial calf area and a large black eschar area on the anterior lower extremity. The left lower extremity photographs pictured four dark areas on the posterior calf and opened reddened areas on the front of the left extremity. Photographs were also taken of the patient's buttock area and scrotum which showed excoriated opened areas. No description of the wounds were documented on the wound documentation form.

Review of the policy and procedure titled Wound Risk Assessment/Prevention/Management revealed:
I. Purpose:
A. For the purposes of this policy Decubitus Ulcers, Pressure Ulcers, Stasis Ulcers and Skin Breakdown are referred to as Wounds...;
B. Targeted Assessment for identification of patients At Risk to develop wounds and implementing interventions are key to preventing acquired wounds;
C. Prompt identification of any and all acquired wounds in any level of care; and
D. Reduce incidence and severity of acquired wounds.
II. Policy:
E. Thorough documentation of the wound assessment including photography of all wounds at all stages whether acquired or pre-exiting after patient consents to photograph.
IV. Incident Reporting of Acquired Wounds.
A. All Stage I or greater wounds should be color photographed by the assessing nurse upon discovery or admission and as needed but no less than weekly...

Further review of patient #5's medical record revealed on 9/1/14 at 11:50 a.m., S17 RN documented "Elevated leg has trouble staying in position on the pillow. Improvised an IV pole and folded sheet tied into a sling hung from the IV pole. Placed two ABD (Abdominal) pads on sling base, in contact with heel of foot. Foot elevated off of bed successfully."

Further review of the wound care policy revealed there failed to be evidence hanging a patient's leg in a sheet sling from an IV pole was an acceptable way of elevating an extremity.

Interview with S17 RN on 11/19/14 at 11:30 a.m. revealed at the time he was assigned the care of patient #5, he was in orientation and S8 RN was his proctor. When asked about the elevation of patient #5's extremity, S17 RN replied that the S11 Physician wanted the patient's right extremity elevated and since the extremity would not stay on the pillow, he improvised a sling using a sheet tied to an IV pole. Review of the nursing notes revealed the nursing staff documented the right extremity remained in the sling until the patient's discharge on 9/2/14 at 4:35 p.m.

Interview with S8 RN on 11/18/14 at 2:15 p.m. revealed she was the nurse proctor for orientee S17 RN in September 2014. When questioned about the elevation of patient #5's right extremity in a sling, S8 RN replied some of the nursing staff did not know that the foot of the beds had a metal bar that could be raised in order to elevate an extremity. There failed to be documented evidence S8 RN implemented this process for patient #5, instead leaving the right extremity in the sheet sling.

Further review of patient #5's medical record revealed on 17 RN documented on 9/2/14 at 7:35 a.m. "...Drainage from wounds running down leg, causing and risking further skin breakdown and risk for breakdown near knee. Surgical petroleum applied to non-broken skin on back of calf and rear upper thigh. Visually appears that drainage runs to petroleum jelly skin and falls to pad beneath immediately." 9/2/14, 9:20 a.m. "...Leg in sling readjusted for elevation. Applied surgical petroleum jelly to undamaged skin along backside of right calf to prevent drainage from sticking to damaged skin. Fluid appears to run off of petroleum jelly-infused skin and drip to pad without incident."

Further interview with S17 RN on 11/19/14 at 12:00 p.m. revealed when asked about the "surgical petroleum jelly" is was revealed this was actually a water soluble gel and not a petroleum based jelly as identified by S17 RN.

Based upon review of 1 of 6 medical records and nursing care plans (#5) and staff interviews, the Registered Nurse failed to ensure patient #5's nursing care plan was developed to include interventions for elevation of the patient's lower extremities. Findings:

Review of patient #5's medical record revealed upon admission to the hospital on 8/13/14, the patient was experiencing edema to the bilateral lower extremities and had sores to the right extremity and skin discoloration to the left extremity. Review of the plan of care revealed the only problem identified related to edema the alteration in Cardiac output/perfusion related to Hemodynamic Instability and Edema. Further review of the plan of care revealed alterations of skin integrity was identified; however, there failed to be interventions related to the elevation of the extremities and the wound care ordered by S11 Physician.

Further review of patient #5's medical record revealed S17 RN documented on 9/1/14 at 11:50 a.m. "Elevated leg has trouble staying in position on the pillow. Improvised an IV pole and folded sheet tied into a sling hung from the IV pole. Placed two ABD pads on sling base, in contact with heel of foot. Foot elevated off of bed successfully"

Interview with S8 RN on 11/18/14 at 2:30 p.m. revealed when asked about the elevation of patient #5's bilateral lower extremities, S8 RN replied some of the nursing staff did not know that the end of a patient's bed could be elevated by engaging the metal bar located under the foot of the bed.

Further review of patient #5's plan of care revealed the nursing staff failed to develop interventions to be utilized related to appropriate techniques for elevation of a patient's extremities.