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Based on observations, medical records and document review and interviews it was determined the facility failed to ensure patient grievances are reported for follow-up investigation and resolution as per hospital policies in one (1) out of ten (10) patients (patient #2). This failure has the potential to place all patients at risk to have their right for prompt resolution of their grievances denied.

Findings include:

1. Patient #2's intravenous (IV) access bled after the catheter was removed and a gauze and tape bandage had been applied. He bled onto his siderails, the floor and his clothes. The bleeding was sufficient to require housekeeping for clean-up. Care for the bleeding site was initially provided by the patient care technician (PCT) without the direction of a Registered Nurse (RN). The PCT removed the dressing, found the site was still bleeding, provided pressure and changed the dressing. The RN was not present during the procedure to assess or assist with care.

2. Patient #2's wife called the facility after the patient was discharged home and filed a verbal grievance with RN #1 who provided care to the patient. RN #1 notified the House Supervisor who was present on the unit at the time the call was received. Neither RN #1 nor the House Supervisor filed an incident report. The PCT had not filed an incident report. As advised by the House Supervisor, RN #1 sent a memorandum about the incident and the call from patient #2's wife to the Unit Manager (UM). The memorandum was sent on 3/9/19. The UM read the memorandum on 3/11/19. After reviewing the event the UM failed to file an incident report and failed to provide follow-up re-education/re-training to staff.

Based on document and record review, interviews and observation it was determined the facility failed to ensure patient's rights requirements are met in one (1) out of ten (10) patients reviewed (patient #2). This failure has the potential to place all patients at risk for having their rights denied.

Findings include:

1. Patient #2 experienced bleeding from his intravenous (IV) site after the catheter was removed on 3/9/19. Intervention for the bleeding was initially provided by a patient care technician (PCT) without assessment and direction of a Registered Nurse (RN).

2. Patient #2's wife called the facility after the patient was discharged home and filed a verbal grievance with the RN who provided care to the patient. The RN notified the House Supervisor who was present on the unit at the time the call was received. As advised by the House Supervisor, the RN sent a memorandum about the incident and the call from patient #2's wife to the Unit Manager (UM) on 3/9/19. The UM read the memorandum on 3/11/19. Neither the RN, the House Supervisor nor the UM filed an incident report. After reviewing the event the UM failed to follow-up by providing re-education/re-training to staff.

Based on observation, document and medical record review and interviews it was determined the facility's Quality Assurance department failed to track patient care in one (1) out of ten (10) patients reviewed (patient #2). The facility failed to track bleeding after removal of intravenous (IV) access devices in patients on blood thinners. This is considered a high-risk, high-volume problem-prone indicator which was not being reported to nor followed by Quality Assurance. This failure has the potential to place all patients on blood thinners with an IV access at risk for harm from bleeding.

Findings include:

1. Patient #2's intravenous (IV) access bled after the catheter was removed and a gauze and tape bandage had initially been applied. He bled onto his siderails, the floor and his clothes. The bleeding was sufficient to require housekeeping for clean-up. Care for the bleeding site was initially provided by the patient care technician (PCT) without the direction of a Registered Nurse (RN). The PCT removed the dressing, found the site was still bleeding, provided pressure and changed the dressing. The RN was not present during the procedure to assess or administer care.

2. Patient #2's wife called the facility after the patient was discharged home and filed a verbal grievance with RN #1 who provided care to the patient. RN #1 notified the House Supervisor who was present on the unit at the time the call was received. Neither RN #1 nor the House Supervisor filed an incident report. The PCT had not filed an incident report. As advised by the House Supervisor, RN #1 sent a memorandum about the incident and the call from patient #2's wife to the Unit Manager (UM). The memorandum was sent on 3/9/19. The UM read the memorandum on 3/11/19. After reviewing the event the UM failed to file an incident report and failed to provide follow-up re-education/re-training to staff.

3. An interview was conducted with RN #2 on 3/18/19 at 1:15 p.m. She revealed that bleeding in patients on blood thinners who have an IV access is not uncommon on the sixth (6th) floor unit. She stated she did not consider the bleeding experienced by patient #2 as notable, therefore did not file an incident report.

4. An interview was conducted with the System Director of Quality on 3/19/19 at 12:55 p.m. She revealed Quality Assurance would address any issue regarding patient care after two (2) incidents were reported. She stated she has received no incident reports concerning patient bleeding after removal of IV catheters from the sixth (6th) floor unit. She further revealed she would consider this type of occurrence notable enough to warrant filing an incident report.

Based on review of documents and medical records, observation and interviews it was determined the facility failed to provide care in a safe setting in one (1) out of ten (10) patients reviewed (patient #2). The facility failed to ensure a Registered Nurse (RN) conducted an assessment and direct the care of patient #2 when he began bleeding after an intravenous (IV) catheter was removed from his arm. The patient was on three (3) blood thinners. This failure has the potential for harm to all patients by receiving care which is not directed under the supervision of a RN.

Findings include:

1. Patient #2 is a sixty-five (65) year old male admitted to the sixth (6th) floor telemetry unit as an observation patient from 3/8/19 to 3/19/19 with diagnosis of status post left cardiac percutaneous cardiac catheterization right wrist. The sixth (6th) floor is a twelve (12) bed telemetry unit.

2. An interview was conducted with the sixth (6th) floor Unit Manager on 3/18/19 at 12:35 p.m. She stated it is her expectation the Registered Nurses on her units are always assessing the patients and intervening appropriately as per hospital policy. She stated she was notified of the incident on 3/11/19 via a memo. She stated she reviewed the incident and determined no re-training or re-education was warranted, therefore she did not provide it. When questioned she stated no one had filed an incident report and she did not file one.

3. An interview was conducted with the PCT on 3/19/19 at 8:40 a.m. She stated patient #2 called out using the call bell and said he was bleeding. The PCT stated in part, "I went into the room and patient #2 had blood all over him and the blankets, arms and belly." The PCT stated she had to go out of the room to get gauze and tape. She then returned to the room and removed patient #2's dressing, at which time the site was still bleeding. She stated in part, "I put pressure on the site for a few minutes" then she changed the dressing. She stated she had cleaned him up. She revealed she told RN #2 she had put gauze and tape on the site because it was bleeding but it was fine now. She revealed she told the Charge Nurse housekeeping would be needed. She stated she doesn't know if the nurses responded at any time during the situation. She revealed she has done dressing changes in the past. During the interview the PCT reviewed her job description. She stated she acknowledged the job description does not include dressing changes.

4. An interview was conducted with the sixth (6th) floor Unit Manager on 3/19/19 at 10:35 a.m. She revealed they stopped allowing PCTs to do dressing changes three (3) years ago because PCTs cannot assess. She stated, at the time this incident occurred, her expectation would be the PCT would reinforce the dressing and notify the nurse.

5. An interview was conducted with the Chief Nursing Officer on 3/19/19 at 2:35 p.m. She reviewed the job description for a PCT. She stated her expectation in this situation is the PCT would reinforce the dressing and notify the nurse either by calling out or by using the call bell. She stated the PCT should not have left the room to get a bandage to take back to the room to perform a dressing change herself.

6. A review of patient #2's clinical record revealed no nurses notes were made about bleeding after his IV was removed. The record does not reveal any teaching done by staff for bleeding precautions after discharge.

7. A review of policy titled IV Dressing Change revised 5/18/18, which cites The Infusion Nurses Society recommendations states in part: "Change a gauze dressing...immediately if the dressing becomes damp, loosened or visibly soiled.."

8. A review of document titled Position Description Patient Care Technician (PCT) revealed it states in part: "Properly and promptly notifies appropriate clinical staff (RN, LPN, supervisor or physician) of patient's special needs, emergency situations or other observations which cause concern."