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Based on policy and procedure review, review of grievance logs and staff interviews the facility staff failed to respond to a grievance within the required timeframe in one of three grievances reviewed. (Pt #4)

The findings include:

Review on 03/17/2016 of the policy and procedure "Patient Grievance Process" (effective date September 16, 2015) revealed, "Policy: ... recognizes that patients have the right to voice concerns without fear of discrimination or reprisal, and have these concerns reviewed and responded to in a timely manner. (Facility name) seeks to provide prompt review and timely resolution of complaints and grievance from any patient. ... Definitions: ... 2. A post - visit complaint from a patient or legal representative who calls or writes to (facility name) concerning issues not resolved during their stay or visit. ... Response to a Grievance ... 4. Within seven calendar days the patient or legal representative will be notified by the Office of Patient Experience which addresses resolution or notifies the patient or representative that further investigation is required. The patient will be informed of the expected follow-up time to address he resolution and will be kept informed of the progress on a weekly basis. All grievance will be resolved as soon as possible with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 days. ..."

Review of the facility grievance log on 03/16/2016 revealed, no documentation that a written or verbal complaint was received by Pt #4's family.

Interview on 3/17/2016 at 1005 with Administrative Staff (AS) #1 revealed Pt #4's family told her (AS #1) she would be contacting the "Patient Experience Department" regarding her stay on the day of discharge.
Interview revealed AS #1 was not familiar with the grievance process. Interview revealed AS #1 did not have a need to notify the "Patient Experience Department" because the patient and her sister were "okay" and "seemed fine" at discharge.

Group Interview on 03/17/2016 at 1330 with AS #1, AS #2, and AS #3 revealed, a Patient Experience Representative (PE Rep) called and spoke with the named patient's sister on 03/07/2016. The patient's sister verbalized her complaint. Interview revealed the PE Rep thought the patient was still hospitalized and called the responsible nursing unit leadership (AS #1) for resolution. Interview revealed AS #1 did not remember receiving a phone call regarding a grievance from the Pt #4. Further interview revealed the patient was already discharged at the time of the call. Interview revealed the grievance should have been handled by the PE Rep and not the nursing unit because the named patient was discharged on 03/01/2016. Interview revealed there was no notification made to the family or the patient by the Office of Patient Experience within 7 days of receipt of the grievance addressing resolution or the need for further investigation. Interview revealed the call was logged as a grievance on 03/17/2016.

Based on policy and procedure review, medical record review and staff interview nursing staff failed to administer an antibiotic as ordered by the physician in one of four surgical records reviewed (Pt #4) and failed to administer the lowest dose of pain medication as a first dose when the physician ordered pain medicine using a range order in two of four surgical records reviewed. (Pt #3 and Pt #4)

The findings include:

Review of policy and procedure on March 17, 2016 "Medication Administration and Bar - Code Scanning (effective date 11/2012) revealed, "Policy: All patients' medications will be administered and documented accurately, appropriately, and in a timely manner, based on physician orders, hospital policy, applicable Standards of Care, and state and federal laws. Purpose: To provide quality patient care through safe administration of medications. Patients will receive medications according to the "Seven Rights": The right patient will receive the right medication, in the right dosage, at the right time, by the right route. The medication will be documented the right way. The patient's right to refuse medication will be respected and acknowledged. ... Medication range orders are permitted as long as the Medication Range Orders Policy is followed. ..." The policy does not refer to medications that are ordered on call to the operating room (OR).

Review of policy and procedure on March 17, 2016 "Medication Range Orders" (Effective date January 2016), revealed ... PROCEDURE: 1. For medication orders that contain a range in dosage: a. the first dose administered should be the lowest in the range. Example: For an order for "Percocet (pain medicine) 1-2 tablets PO (by mouth) q4h (every 4 hours) prn (as needed) moderate pain," the first dose given should be 1 tablet."

1. Review of the Patient #4 (Pt #4) medical record on 03/17/2016 revealed she was admitted on 02/28/2016 with right hip pain. Medical evaluation revealed the patient had a right femoral neck fracture (broken hip). Review revealed Pt #4 had a right hip arthroplasty (hip replacement) on 02/29/2016. Review of a physician order written on 02/28/2016 at 1322 revealed "Cefazolin (Ancef {antibiotic}) IVPB (intravenous) 2g (grams)/50 mL (milliliters) premix Frequency: On all to OR (operating room) @ 100 mL/hr over 30 minutes." Review of the MAR (medication administration report) revealed Ancef 2g IV over 30 minutes was administered on 03/29/2016 at 1000 (4 hours and 10 minutes prior to surgery). Review of a nursing note dated 02/29/2016 at 1246 revealed, "Family member reports that she is concerned about timing that ancef was given. Ancef was noted to be given at 1000. Notified Dr. {physician's name} who stated to dose with additional 1 gram. Family member notified." Further review revealed an additional dose of Ancef 1gm IV over 30 minutes times one dose was ordered by the surgeon on 2/29/2016 at 1250. Review revealed 1 gm of Ancef IV was administered over 30 minutes on 02/29/2016 at 1300. Review of the operative flowsheet revealed the first surgical incision was made at 1410.

Interview with Administrative Staff (AS) #1 on 3/17/2016 at 1005 revealed, the Ancef was administered 4 hours early. Interview revealed, there was a timing error by the pharmacy, but, there was a comment with instructions to administer the antibiotic on call to OR. Interview revealed the administering RN was provided individualized education and nursing team was reeducated during a daily huddle (short meeting).

2. Medical record review on 03/17/2016 of Pt #4 revealed she was admitted on 02/28/2016 with right hip pain. Medical evaluation revealed Pt #4 had a right femoral neck fracture (broken hip). Review revealed the patient had a right hip arthroplasty (hip replacement) on 02/29/2016. Further review revealed the patient had an uncomplicated post-operative period and was discharged on 03/01/2016. Review of physician orders dated 02/28/2016 at 1322 revealed a range order for "Hydrocodone (Norco/Vicodin) 5-325 mg per tablet 1-2 tablet oral every 4 hours PRN for moderate pain." Review revealed the named patient complained of acute, aching, right hip pain rate of 9 at 1418 " Review revealed the patient received two Hydrocodone tablets at 1417, her first dose. Review revealed the named patient was given 2 Hydrocodone tablets instead of one for her first dose.

Interview with Administrative Staff #4 on 03/16/2016 at 1050 revealed the lowest dose of medication should be given as the first dose when a range order is written. Interview revealed the range order policy was not followed.

3. Medical record review on 03/17/2016 of Pt #3 revealed she was admitted on 02/09/2016 with left hip DJD (degenerative joint disease). Review revealed Pt #4 had a left hip arthroplasty (hip replacement) on 02/09/2016. Further review revealed Pt #3 had an uncomplicated post-operative period and was discharged on 02/12/2016. Review of physician orders dated 02/09/2016 at 1230 revealed a range order for "Hydromorphone (pain medicine) injection 0.5 - 1 mg (milligram) Intravenous every 3 hours PRN (as needed) for severe pain, unresolved breakthrough pain." Review revealed the named patient complained of surgical pain rate of 8 at 1338 on 02/09/2016. Review revealed the patient received 1 mg of Hydromorphone at 1335, her first dose. Review revealed the Pt #3 was given 1 mg of Hydromorphone intravenous instead of 0.5mg Hydromorphone for her first dose.

Interview with Administrative Staff #4 on 03/16/2016 at 1050 revealed the lowest dose of medication should be given as the first dose when a range order is written. Interview revealed the range order policy was not followed.

4. Medical record review on 03/17/2016 of Pt #3 revealed she was admitted on 02/09/2016 with left hip DJD (degenerative joint disease). Review revealed Pt #3 had a left hip arthroplasty (hip replacement) on 02/09/2016. Further review revealed Pt #3 had an uncomplicated post-operative period and was discharged on 02/12/2016. Review of physician orders dated 02/09/2016 at 1230 revealed a range order for "Hydrocodone (Norco/Vicodin) 5-325 mg per tablet 1-2 tablet oral every 4 hours PRN for breakthrough pain." Review revealed the named patient complained of surgical pain rate of 8 at 1338 on 02/09/2016. Review revealed the patient received two Hydrocodone tablets at 1435, her first dose. Review revealed the Pt #3 was given 2 Hydrocodone tablets instead of one for her first dose.

Interview with Administrative Staff #4 on 03/16/2016 at 1050 revealed the lowest dose of medication should be given as the first dose when a range order is written. Interview revealed the range order policy was not followed.

Based on review of policy and procedure observation during tour and staff interview, facility staff failed to date and label open containers and to remove expired food items from the patient nourishment refrigerators in two of three unit tours and failed to maintain an environment to ensure the safety of patients as evidenced by improper storage of oxygen cylinders in one of three unit tours.

The findings include:

1. Review of Hospital policy titled, "Compressed Gas Cylinders", with effective date of August 27, 2015 revealed "Procedure: Extra care must be taken to avoid breaking the valve from a full compressed gas cylinder. Breaking off a valve from a full compressed gas cylinder can be extremely dangerous. Securing Cylinders: Full, ready for use, and empty cylinders shall be secured by approved methods to prevent tipping over and falling."

Observation during tour of soiled utility room on 03/16/2016 at 1055 with Administrative staff (AS) #5 revealed 2 portable oxygen tanks unsecured sitting on a four-legged low stool in the room.

Interview with RN (# ) on 03/16/2016 at 1110 revealed charge nurse is responsible to take oxygen tanks downstairs. "Charge nurses are assigned to take used oxygen tanks to loading dock downstairs. Oxygen tanks should be stored in containers and not on stool."

Interview during tour on 03/16/2016 at 1055 with AS #5 revealed oxygen tanks should be stored securely. Interview confirmed oxygen tanks were not stored appropriately.



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2. Review of policy and procedure on 03/16/2016 "Food Storage" (effective date 6/2003) revealed. "PURPOSE: To ensure food shall be clean, free from spoilage, free from adulteration and misbranding and safe for human consumption. ... Food brought in from the outside by visitors of patients must be consumed immediately or stored separately from the institutions food supply. ...food must be labeled with the patient's name, room number, and date food was brought in. ...Employees' food brought from the outside must be stored separately from the institution's food supply. ..."

Unit tour on 03/16/2016 from 1050 to 1130 revealed two patient nourishment rooms on each end of the unit. Observation revealed a patient nourishment refrigerator in room N157. Observation revealed two of four sandwiches with expirations dates of 03/14 and 03/15 on the labels. Observation revealed two expired bottles of tube feeding with the expiration date 03/15/2016 (pharmacy label) on the label. Further observation revealed an open bottle of "Ensure" which was not labeled with a patient name or the date it was opened and placed in the refrigerator. Observation revealed a cup in the freezer with "Cookout" on the label. The contents were partially consumed. Observation revealed the cup was not labeled with a patient name or the date it was placed in the freezer. Observation revealed a patient nourishment refrigerator in room N121. Observation revealed one of two sandwiches were expired with an expiration date of 03/14/2016. Further observation revealed an open bottle of "Ensure" which was not labeled with a patient name or the date it was opened. Observation revealed expired food and unlabeled, partially consumed food products in two of two patient nourishment refrigerators on the floor.

Interview with charge nurse during on 3/16/2016 during unit tour revealed expired foods should be removed and thrown away. Further interview revealed open containers should not place in or returned to the patient nourishment refrigerator.

Interview with Administrative Staff (AS) #2 on 03/17/2016 at 1005 revealed the food should have been discarded and the open containers should not be returned to the patient nourishment refrigerator. Interview revealed AS #2 is working on a "strategy to check the nourishment refrigerators" which would include reviewing expiration dates. Review revealed AS #2 has been talking with dietary and has requested that foods with the longest expiration dates be placed behind the food products that expire the soonest. Interview revealed, the secretary will be responsible for checking the patient nourishment refrigerators on the weekends.

Unit tour (the same unit toured on 03/16/2016) on 03/17/2016 at 1000 revealed two patient nourishment rooms on each end of the unit. Observation revealed a patient nourishment refrigerator in room N157. Observation revealed an expired sandwich with the expiration date 3/16/2016. Further observation revealed an open bottle of "Ensure" which was not labeled with a patient name or the date it was opened and placed in the refrigerator. Observation revealed expired food and unlabeled, partially consumed food products in one of two patient nourishment refrigerators on the floor.

Interview with Administrative Staff (AS) #2 on 03/17/2016 at 1005 revealed the food should have been discarded and the open containers should not be returned to the patient nourishment refrigerator. Interview revealed AS #2 is working on a "strategy to check the nourishment refrigerators" which would include reviewing expiration dates. Review revealed AS #2 has been talking with dietary and has requested that foods with the longest expiration dates be placed behind the food products that expire soonest. Interview revealed, the secretary will be responsible for checking the patient nourishment refrigerators on the weekends.
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