HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of 1 patient with 21 records reviewed. Based on policy review, document review, and staff interview, the CAH failed to contact the person submitting the grievance and assure them that it is being investigated, and to contact the person filing the grievance by mail or by telephone within 7 days of completing the investigation process.

Findings include:

- The CAH's policy "Grievance Policy" reviewed on 9/30/13 at 4:30pm of revealed "...the person submitting the grievance will be contacted and assured that it is being investigated. Within seven (7) days of completing the investigation process, the person filing the grievance will be contacted by mail or by telephone".

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 11/14/12. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 11/20/12. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 1/7/13. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 1/9/13. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 1/18/13. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 11/20/12. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance filed on 7/31/13. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

- The CAH grievance log reviewed on 9/30/13 at 2:00pm, revealed a grievance note on 8/20/13. The grievance log lacked evidence of contacting the person submitting the grievance of an investigation, and lacked evidence of contacting the person filling the grievance within 7 days of completing the investigation process. The CAH failed to follow its policy for the grievance process.

Staff B, RN, Risk Manager, and Quality Assurance Coordinator interviewed on 9/30/13 at 4:30pm acknowledged the CAH failed to follow its policy for the grievance process.

The Critical Access Hospital (CAH) reported a census of 1 patient with 21 records reviewed. Based on observation, policy review, record review, document review, and staff interview, the CAH failed to ensure nursing staff follow their policy for restraints; and failed to meet the needs of the patients by ensuring nursing staff identify and implement nursing cares to meet the needs of patients.

Findings include:

- The CAH policy "Nursing Policy and Procedure-Restraints" reviewed on 10/1/13 and last revised on 8/9/12 revealed "...the application of restraint respects the patient as an individual...restraints are issued with the physician's verbal or written order in accordance with a written modification to the patient's plan of care..."

- The CAH grievance log reviewed on 9/30/13, revealed on 1/18/13 "parent of patient #21 entered the room and found patient arm was tied to the bed rail". Subsequent investigation by the CAH revealed patient #21 was sleeping and kept bending arm causing intravenous catheter (IV) to occlude. Staff C, a licensed practical nurse (LPN) on orientation, approached patient #21 and asked if arm could be secured as a reminder not to bend. Staff C obtained a pair of mesh panties from the supply cart and tied the patient arm to the bed rail. Patient #21 did not remember the conversation with Staff C.

- Patient #21's medical record reviewed on 9/30/13 revealed an admission date of 1/16/13 with diagnosis of arrhythmia (heart irregularity), hypertension (high blood pressure), and anxiety after ingesting 16 cough and cold pills. Patient #21's medical record revealed on 1/17/13 at 1350 (1:50pm) the patient's left hand was found tied to the bedrail, origin unknown. The medical record lacked a physician order, a written modification to the patient's plan of care, and documentation of the application and clinical justification for the restraint.

Staff B, Registered Nurse (RN), Risk Manager, and Quality Assurance Coordinator interviewed on 9/30/13 at 3:30pm acknowledged nursing staff restrained patient #21 without a physician order, and that the medical record also lacked a written modification to the patient's plan of care, and documentation of the application and clinical justification for the restraint.

- The CAH grievance log reviewed on 9/30/13 revealed on 8/20/13 Patient #6 was visited by Staff A, RN and Director of Nursing, and Staff B, RN, Risk Manager, and Quality Assurance Coordinator to discuss concerns with nursing care. Subsequent investigation by the CAH revealed patient #6's medical record lacked nursing cares to meet the needs of patients.

- Patient #6's medical record reviewed on 9/30/13 revealed an admission date of 8/18/13 with diagnoses of Fentanyl (narcotic pain medication) and sepsis (inflammation in the whole body). Patient #6's medical record revealed at admission, bedrest was ordered by the physician, and the nursing assessment on 8/18/13 acknowledged bedrest under "activity level" and included skin plan of care. Nursing documentation on 8/18/13, 8/19/13, 8/20/13, and 8/21/13 failed to identify and implement patient bathing hygiene, combing of hair, or oral hygiene.

Staff B, RN, Risk Manager, and Quality Assurance Coordinator interviewed on 9/30/13 at 4:10pm acknowledged patient #6's medical record failed to identify and implement patient bathing hygiene, combing of hair, or oral hygiene.