HospitalInspections.org

Based on record review and interview, the hospital failed to ensure provision of date of completion of the grievance process for one (Patient #1) of one patients.

This failed practice has the likelihood to place patients at risk for development of mistrust in the hospital's grievance process, thereby, leading to patient reluctance to report problems in the future.

A review of a hospital policy titled "Patient Grievance/Complaints" read in part, "The Grievance Officer...provides the patient with written notice of its decision. The decision must contain...the date the grievance process was completed."

Findings:

Patient #1

A review of a grievance resolution letter drafted for Patient #1 did not show a date of completion.

On 01/07/21 at 12:19 PM, Staff G reviewed the grievance policy and the grievance resolution letter for Patient #1 and stated there was no date on the letter.

Based on record review and interview, the hospital failed to ensure documentation of nursing assessment for one (Patient #3) of six patients.

This failed practice has the likelihood to place patients at risk of not having their clinical conditions and needs identified.

A review of policy titled "Standards of Patient Care P&P #: ED 2001" read in part, "The Registered Nurse performs a comprehensive nursing assessment...Data Collection is systematic and comprehensive. Data is obtained through...physical examination...Assessments...are thoroughly documented...in the emergency department nursing notes...nursing flowsheets."

Findings:

Patient #3

A review of the medical record showed a nursing note dated 07/04/20 11:00 AM that read in part, "Parents state joint stiffness...Parent states abdominal pain...wheezing," and did not show musculoskeletal, gastrointestinal, or respiratory nursing assessments.

On 01/06/21 at 12:38 PM, Staff C reviewed the medical record for Patient #3 and stated:
1. There was no documented nursing assessment to show auscultation of lung or abdominal sounds
2. The risk to the patient included not having their underlying issues addressed or receiving treatment that was not consistent with their condition.

Based on record review and interview, the hospital failed to ensure discharge instructions were provided to patients for one (Patient #4) of six patients.

This failed practice has the likelihood to place patients at risk of knowledge deficit of follow-up care, thereby increasing the likelihood for a hospital readmission.

A review of a policy titled "Discharge Procedures P&P #: SS 1030" read in part, "Written and Verbal Instructions: Provided to each patient and should reflect the patient's individual needs specific to homecare and response to unexpected events and follow-up by physician...Place a copy of the signed post-operative instructions in the medical record."

Findings:

Patient #4

A review of the medical record showed no documentation of signed post-operative discharge instructions.

On 01/06/21 at 3:50 PM, Staff E reviewed the medical record for Patient #4 and stated:
1. There was no signed discharge instructions in the chart.
2. He or she recalled this case and the nurse should have made a note that the doctor's office opted to give the discharge instructions to the patient.

On 01/07/21 at 11:25 AM, Staff C stated discharge instructions were absolutely to be included as part of the medical record.

Based on record review and interview, the hospital failed to ensure medical record entries were authenticated and timed for two (Patients #2 & #3) of six patients.

This failed practice has the likelihood to place patients at risk of delayed or inaccurate communication between healthcare providers as the medical record provides a sequential record of patient care through timely documentation of physical assessments and interventions to decrease adverse health outcomes and ensure quality patient care.

A review of a document titled "Medical Staff Rules and Regulations" read in part, "All clinical entries and summaries in the patient's medical record shall be accurately dated, timed and authenticated."

Findings:

Patient # 2

A review of a document titled "Physician Assessment" showed no physician signature, no date of assessment, and no time of record entry.

A review of documents titled "Progress Notes" and "Physician's Orders" dated 09/04/20 showed no time of record entry.

On 01/06/21 at 12:15 PM, Staff D reviewed the medical record for Patient #2 and stated doctors were supposed to sign, date and time all entries they made in a patient's chart and they did not for this patient.

Patient #3

A review of a document titled "Physician Assessment" showed no date of assessment and no time of record entry.

On 01/06/21 at 12:38 PM, Staff C reviewed the medical record for Patient #3 and stated the history and physical was not timed or dated by the physician and should have been.

Based on record review and interview, the hospital failed to ensure completion of history and physical for one (Patient #3) of six patients.

This failed practice has the likelihood to place patients at risk of receiving poor quality of care from uninformed medical care decisions by healthcare providers.

A review of a document titled "Medical Staff Rules and Regulations" read in part, "The attending practitioner will be responsible for the preparation of a complete and legible medical record for each patient. Its content...shall include...medical history, family history and history of the present illness."

Findings:

Patient #3

A review of a document titled "Physician Assessment" showed no medical history, family history, or history of the present illness for the patient's 07/04/20 hospital visit.

On 01/06/21 at 12:38 PM, Staff C reviewed the medical record for Patient #3 and stated the physician did not complete a medical history or review of medications and should have to inform decisions for care.