HospitalInspections.org

Based on hospital policy and procedure review, grievance file review and staff interview, the hospital staff failed to provide written notice of the resolution of a grievance in 2 of 2 grievances reviewed (Grievance #5 and #8).

The findings include:

Review of hospital policy and procedure "Grievance.com" approved January 2009 revealed a grievance is defined as "A written or verbal complaint (when the verbal complaint about patient is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. ...2. Grievances about situations that endanger the patient, such as abuse or neglect, will be reviewed and responded to immediately. ...5. In the case of a grievance, most situations will be resolved and the patient notified of the resolution by letter from the Patient Relations Representative within (7) seven days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, and the date of completion (indicated by the date of the letter to the patient)."

1. Interview on 08/11/2010 at 1340 with a risk management staff member revealed Patient #5's (Grievance #5) family member had called the risk manager on 06/07/2010 to notify her that the patient had been "struck by a staff member" over the weekend. Interview revealed a meeting was arranged with the patient's family on 06/07/2010 to discuss the abuse allegation. Interview revealed other care issues were identified as complaints during the meeting. The staff member stated the investigation was started immediately and the staff member involved was suspended pending investigation results. Interview revealed another family meeting was held on 06/10/2010 to discuss ongoing complaints related to medications and discharge plans. Interview revealed the patient's physician was present at this meeting to discuss medication concerns. Interview revealed the abuse allegation was not substantiated and care issues related to medication concerns were thought to be resolved to the family member's satisfaction after the meeting on 06/10/2010.

Review of the hospital grievance log from June 1, 2010 through August 10, 2010 revealed no evidence of a grievance filed on behalf of Patient #5.

Interview on 08/11/2010 at 1340 with a risk management staff member confirmed the hospital staff failed to treat the complaints as a grievance and failed to send a written response. The staff member revealed the complaints should have been treated as a grievance and a written response of the resolution should have been sent. Interview confirmed that the staff failed to follow the hospital's grievance policy and procedure.

2. Review of the hospital's grievance log revealed a grievance was filed on 07/19/2010 (Grievance #8) by Patient #8's family member regarding lack of nursing supervision and monitoring following surgery resulting in complications. Review of a written "Summary of Conversation" documented by the Patient Relations Representative signed by the complainant on 07/22/2010 revealed the complaints included failure of the surgeon to inform the patient of surgical complications prior to surgery and failure of nursing staff to be adequately trained to monitor and supervise post surgical nursing care for Patient #8.

Interview on 08/11/2010 at 1820 with a risk management staff member revealed the patient's family member had presented in person to the patient representative staff member on 07/19/2010 with complaints. Interview revealed the patient was admitted on 07/14/2010 for gallbladder surgery. Interview revealed the common bile duck was "nicked" during surgery, the patient developed complications and expired on 08/01/2010. Interview revealed the complaint was investigated and nursing care, supervision and response was determined to be appropriate. The staff member stated the case was reviewed by the hospital's Chief Medical Officer and would be going for peer review in October. Record review revealed a surgical informed consent was signed by the patient prior to surgery that stated that complications of the surgical procedure were explained. Interview revealed no written response to the grievance was sent to the family member. Interview revealed that the patient's condition deteriorated and it didn't seem like an appropriate time to provide the written response. Interview confirmed that the staff failed to follow the hospital's grievance policy.

Based on review of hospital policy and procedures, medical record review and staff interviews the nursing staff failed to administer blood transfusions according to hospital policy for 2 of 3 sampled patients that received a blood transfusion (#3 and #4).

The findings include:

Review of the hospital's Blood Administration policy approved May 2010 revealed vital signs (temperature, pulse and blood pressure) are to be obtained and documented prior to starting the blood transfusion, 15 minutes after the transfusion started and 1 hour after the transfusion is completed. Further review of the policy revealed that packed red blood cells are to be infused within four hours after removal from the blood bank.

Review of the Blood Transfusion Reaction policy approved January 2010 revealed symptoms of a transfusion reaction include "elevated temperature (2 degrees or greater)." The policy states if any of the transfusion reaction symptoms occur, the nurse should stop the transfusion, check vital signs and notify the physician immediately for further treatment.

1. Closed medical record review of Patient #3 revealed an 88 year-old female who was admitted on 07/09/2010 with pneumonia. Record review revealed the patient was treated and subsequently discharged on 07/26/2010. Record review revealed on 07/09/2010 the patient received a transfusion of packed red blood cells. Record review revealed the transfusion was started on 07/09/2010 at 1515 and was completed at 2025 (5 hours and 10 minutes after starting). Record review revealed documentation of vital signs at 1339 (prior) and 2124 (1 hour after transfusion ended). Record review revealed no documentation of vital signs 15 minutes after the transfusion was started.

Interview with administrative nursing staff on 08/11/2010 at 1730 confirmed there was no available documentation that the nurse assessed the patient's vital signs 15 minutes after the start of the blood transfusion per policy. Interview revealed the blood should have been discarded four hours after removal from the blood bank. Interview confirmed that the blood transfused over a period of 5 hours and 10 minutes and that the blood should have been stopped and discarded after four hours. Interview confirmed nursing staff failed to follow the hospital's blood administration policy.

2. Closed medical record review of Patient #4 revealed a 72 year-old female who was admitted on 07/13/2010 with nausea, vomiting, diarrhea and neutropenia. Record review revealed the patient was treated and subsequently discharged on 07/22/2010. Record review revealed on 07/15/2010 the patient received a transfusion of two units of packed red blood cells. Record review revealed the second unit of packed red blood cells was started on 07/15/2010 at 1725 and was completed at 1930. Record review revealed documentation of vital signs at 1705 (prior), 1742 (15 minutes after transfusion started) and 1949 (19 minutes after transfusion ended). Further review revealed the patient's temperature was recorded at 1705 as 99.9 degrees Farenheit and recorded at 1949 as 102.6 degrees Farenheit. Record review revealed no evidence that the physician was notified of the increased temperature. Record review revealed no documentation of vital signs 1 hour after the transfusion ended.

Interview with administrative nursing staff on 08/11/2010 at 1725 confirmed there was no available documentation that the nurse assessed the patient's vital signs 1 hour after the completion of the blood transfusion. Interview revealed there was no evidence the elevated temperature was reported to the patient's physician. Interview confirmed a temperature increase of 2 degrees or more after or during a blood transfusion would be considered a possible transfusion reaction and should be reported. Interview confirmed nursing staff failed to follow the hospital's blood administration policy.




NC00065107, NC00066585