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Based on review of hospital policy, grievance file review, and staff interview, the hospital staff failed to investigate and resolve a grievance for 1 of 6 patient's (patient #16) and failed to provide a written response per specified time frame for 1 of 6 grievances reviewed (#16).

The findings include:

Review of the hospital's policy "Policy and Procedure Bulletin: Patient Grievance Process" revision date of April 2011 revealed "... Grievance: a "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) made by a patient or patient's representative regarding the patient's care...A written complaint regarding patient care provided or alleging abuse or neglect will be considered a grievance... A complaint/grievance is considered resolved when the appropriate follow-up measures have been taken and a response communicated to the patient and/or legal representative. ...D. Complaints/grievances will be promptly investigated and a response given to the patient within an average of seven working (7) days. If the nature of the complaint/grievance requires longer than seven (7) working days, the patient will be advised in writing of the extension, and notified that they will receive a written response within (30) days. If the nature of the complaint/grievance requires longer than thirty (30) days to investigate, the patient will be advised of an additional extension, and when he/she should receive a response. All grievances will be responded to in writing upon resolution, and will include the steps taken to investigate the grievance, the results of the grievance process, date of completion, and the name of a contact person... 4. Nursing complaints/grievances will be directed to the appropriate unit manager...for investigation and appropriate follow-up...6. Complaints/grievances will be responded to and routed back through the Service Excellence Department where the action taken will be documented. The Service Excellence Department will maintain and file disposition reports of all Medical Center complaints/grievance..."

1. Review of the grievance file for Patient #16 on 04/24/2013 revealed a letter received by the Service Excellence department on 08/06/2012. Review of the letter dated 08/06/2012 revealed concerns related to Patient #16's care while an inpatient from 12/29/2011 through 01/02/2012. Review of the letter revealed a 10 page hand written grievance with a total of 6 complaints identified by the Service Excellence Representative.

Continued review of the file revealed " ...The niece of the patient expressed concern via letter regarding the behavior of a nurse in (nursing unit). The niece states that this nurse did not care for her aunt but rather a patient beside of her (aunt) who happened to be blind (the other patient). The niece states that the nurse treated a blind man (the other patient) like dirt. She said the man was getting on her nerves out loud and the man just needed to pee. The niece feels that no one should be talked to or treated in that manner. " Continued review of the grievance file revealed no documentation of an investigation or resolution related to this complaint.

Continued review of the file revealed " ...The niece of the patient expressed concern via letter regarding a nurse on (nursing unit). The niece states that the nurse was not helpful. The niece states that when they first arrived on (nursing unit) no on knew who was taking care of the patient, including the actual nurse. The niece states that she asked (nurse name) if there were any updates from the doctor and according to the niece, (nurse name) stated no without offering to get a doctor to speak with them. The nieces stated that she requested to speak with a doctor several times during her inpatient stay ...and (named nurse) would not page them. The niece states that (nurse name) didn't seem to like her job. She didn't wash my aunt or rotate her ... " Continued review of the grievance file revealed no documentation of the investigation or resolution of the complaint relating to the care/treatment and lack of assistance to the patient.

Continued file review revealed a written response to the grievance on 09/14/2012 that included outcomes of the investigation. Further review of the grievance file revealed no evidence of an investigation of the allegation.

Interview on 04/24/2013 at 1530 with the Nurse Manager revealed "...anytime there is a complaint or grievance I do an investigation and the findings are reported to the Service Excellence Department ...sometimes Service Excellence calls me and I give them verbal feedback, sometimes it is written through email ...I can't remember the nurses I spoke with about this grievance ...can't remember what my investigation and findings were, I think the person was upset that the patient's hair had not been washed and a bath had not been given...sometimes the corrective action may be a verbal conversation with the person involved and sometimes it may be a formal counseling but I don't remember what was involved in this grievance ...I would have investigated and I would have sent my investigation findings to Service Excellence as required by our policy." Interview with the nurse manager confirmed there is no documentation of the investigation conducted for this grievance in the grievance file.

Interview on 04/24/2013 at 1555 with the patient representative from the Service Excellence Department revealed "...In this particular case (#16) there were so many complaints in the lengthy letter (grievance)...I reviewed and narrowed down what the complaints were and sent those to the particular manager or provider via email requesting their investigation and follow-up. They can also respond by phone and when they do I will write down their investigation and their corrective actions then document them in the resolution section of the grievance summary... I do not see any investigation findings or resolution documented on either of the complaints forwarded to the nurse manager or case manager ...More than likely they phoned and said apologize to the patient. There are no findings or resolution in the folder and I don't recall how I got my findings or investigation in order to resolve the complaint ... the policy is the investigation findings will be sent back to the Service Excellence department and we will keep them in the file ...I do not have anything that shows what was investigated or done. The policy for the (grievance) process is the investigation findings are to be reported back to me in writing ...at times we do not get it back ...I can not find any documentation in the file that shows the investigation was completed by the managers and what actions were taken other than what I put in the letter to the complainant." Interview with the patient representative confirmed there is no documentation of the investigation of the complaint in the grievance file.

2. Review of the grievance file for Patient #16 on 04/24/2013 revealed a letter received by the Service Excellence department on 08/06/2012. Review of the letter dated 08/06/2012 revealed concerns related to Patient #16's care while an inpatient from 12/29/2011 through 01/02/2012. Continued review of the file revealed a letter dated 08/09/2012 to the patient's guardian signed by a staff member in the hospital's Service Excellence Department. Review of the letter revealed, "...Please allow us up to 30 days to review your concerns, by which point I will respond to you in writing. ..." Continued file review revealed a second letter dated 09/14/2012 .(39 days after grievance received) to the complainant , ..."as I relayed to you in my last letter, a formal grievance was filed on your behalf with the Department of Service Excellence on August 6, 2012. Your concern has again been evaluated through our formal complaint process which was established to ensure accountability at the highest level. No additional letters were found in the file.

Interview on 04/24/2013 at 1555 with the patient representative from the Service Excellence Department revealed "once we receive the complaint we mail a letter to the complainant making them aware we have received their complaint and that we will respond in writing within 7 days of our investigation and findings. In this particular case (#16) there were so many complaints to investigate I informed the family in the 08/09/2012 letter that we would respond within 30 days with our findings. We usually respond within 7 days but with this grievance we needed 30 days to investigate and notified the complainant of that. The final letter to the complainant is dated 09/14/2013, a few days past the 30 days." Interview confirmed the hospital's time frames for responding to a grievance was not followed.

Based on policy and procedure review, medical record review and staff interview, the hospital failed to ensure a physician order for a restrained patient for 1 of 2 restrained patients reviewed (#22).

The findings include:

Review of the hospital's policy, "Restraint and Seclusion", revised 06/26/2012, revealed, "...All restraints or seclusion require a physician or LIP (licensed independent practitioner) order. ...Restraint or seclusion orders are valid only for the time limit identified by the physician/LIP. Discontinuation of a restraint...discontinues the order. ...Time limits may not exceed 24 hours. ...".

Open medical record review of Patient #22 revealed a 78 year-old male, admitted on 04/09/2013 with cancer of the oral cavity with subsequent surgery on 04/09/2013. Medical record review revealed the patient was admitted to the surgical ICU (intensive care unit) after surgery. Record review revealed a physician's order dated 04/09/2013 at 1834 for bilateral soft wrist restraints. Record review revealed the restraints were discontinued on 04/10/2013 at 0600 and were reapplied on 04/11/2013 at 1600. Record review revealed no documentation of a physician's order for the reapplication of restraints on 04/11/2013 at 1600. Further record review revealed a physician's order for soft wrist restraints on 04/12/2013 at 0619 (48 hours, 19 minutes after the initial order and 14 hours, 19 minutes after the reapplication of restraints).

Interview on 04/25/2013 at 0830 with RN (Registered Nurse) #1 revealed the RN was Patient #22's primary nurse on 04/10/2013 beginning at 1900. Interview confirmed restraints were reapplied on 04/11/2013 at 1600 after being discontinued on 04/10/2013 at 0600. Interview further revealed there was no physician's order for the reapplication of restraints. Interview revealed, "I called the doctor and he said he would come later and write the restraint order". Interview confirmed Patient #22 was restrained without a physician's order.

Based on policy and procedure review, medical record review and staff interviews, the hospital failed to ensure the monitoring of a restrained patient per hospital policy for 1 of 2 restrained patients reviewed (#22).

The findings include:

Review of the hospital's policy, "Restraint and Seclusion", revised 06/26/2012, revealed, "...D. Assessment and Monitoring Patients in Restraints or Seclusion... Restraints for Nonviolent Reasons Assessment and monitoring for comfort and to prevent complications from mobility and skin breakdown will be completed at least every two hours. ...E. RN (Registered Nurse) Documentation for Restraints or Seclusion ...3. Monitoring of patient safety checks including circulation, skin integrity, and positioning is documented on the appropriate restraint or seclusion flow record. ...".

Open medical record review of Patient #22 revealed a 78 year-old male, admitted on 04/09/2013 with cancer of the oral cavity with subsequent surgery on 04/09/2013. Medical record review revealed the patient was admitted to the surgical ICU (intensive care unit) after surgery. Record review revealed a physician's order dated 04/09/2013 at 1834 for bilateral soft wrist restraints. Record review revealed the restraints were discontinued on 04/10/2013 at 0600 and were reapplied on 04/11/2013 at 1600. Record review revealed no documentation by the RN of monitoring for patient safety checks on 04/11/2013 from 2000 until 04/12/2013 at 0800 (12 hours).

Interview on 04/25/2013 at 0830 with RN #1 revealed the RN was Patient #22's primary nurse on 04/10/2013 beginning at 1900. Interview revealed Patient #22 was restrained with soft wrist restraints on 04/11/2013 beginning at 1600. Interview further revealed, "I didn't document the restraint monitoring because I didn't have an order for the restraints". Interview confirmed the hospital's policy for monitoring and documenting patient safety checks every two hours for patients in restraints was not followed.

Based on policy and procedure review, medical record review and staff and physician interview, the hospital's nursing staff failed to evaluate and supervise the nursing care of patients by failing to reassess pain for 2 of 7 patients receiving pain medications reviewed (#24, #7).

The findings include:

1. Review of the hospital's policy, "Intravenous Patient Controlled Analgesia (PCA)", revised 07/2010, revealed, "...V. PROCEDURE: ...K. Monitoring of the patient is completed on initiation and with any changes made every 2 hours times 12 hours, then every 4 hours: ...Pain assessment and patient observation on the back of the Analgesia Infusion Flowsheet Q(every) 4H (hours)...".

Open medical record review of Patient #24 revealed a 24 year-old female admitted on 04/19/2013 with an ovarian mass with subsequent laparotomy and right salpingo-oophorectomy (removal of fallopian tube and ovary). Record review revealed a physician's order dated 04/19/2013 for a continuous PCA pump with Dilaudid (narcotic pain medication) 0.2 mg (milligrams) per ml (milliliter). Record review revealed documentation of pain assessment on 04/21/2013 at 2351. Record review revealed the patient's pain was not reassessed again until 04/22/2013 at 0700 (7 hours, 8 minutes later). Further record review revealed the patient's pain was assessed on 04/22/2013 at 0913. Record review revealed the patient's pain was not reassessed again until 04/22/2013 at 1906 (9 hours, 47 minutes later).

Interview on 04/24/2013 at 0930 with RN #2 revealed, "a pain assessment should be completed every 4 hours and documented on the flowsheet for any patient on a PCA pain pump". Interview confirmed the nursing staff failed to follow the hospital's policy for monitoring of a patient on a PCA pump.



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2. Review of the "Pain Management Policy" revised June 2010 revealed "... IV. F. Reassessment of pain intensity and pain relief is performed at regular intervals. The same pain intensity rating scale used for assessment should be used for reassessment. The patient's response should be assessed within one hour of an intervention and documented in the medical record."

Closed record review of Patient #7 revealed a 47 year-old male that presented to the emergency department (ED) on 07/29/2012 at 1220 with a chief complaint of back pain. Review of of triage notes revealed the patient complained of back pain at a level of 10 (on a scale of 1 - 10 with 10 being the worst pain). Review of nursing notes revealed the patient was administered Dilaudid (narcotic pain medication) 1 milligram intramuscular at 1421. Further review revealed the patient was discharged home at 1546 (1 hour and 25 minutes after pain medication was administered). Review of the record revealed no documentation of pain after the medication intervention.

Interview on 04/24/2013 at 1320 with a nursing administrative staff member revealed pain should be reassessed one hour after pain medication is administered and prior to discharge from the emergency department. The staff member reviewed Patient #7's ED record and confirmed there was no documentation of pain after medication was administered and prior to discharge. The staff member stated the nurse failed to follow the hospital's policy.

Based on policy review, closed medical record review and staff and physician interviews, the emergency department nursing staff failed to document treatment provided and outcome of the treatment for 1 of 8 emergency department records reviewed (#6).

The findings include:

Review of "Documentation of Patient Care, Treatment, and Services" policy effective 05/14/2012 revealed "... III. N. Medical records shall contain the following information as appropriate to the care and location of the patient: ... 13. Observation relevant to the care, treatment, and services 14. The patient's response to care, treatment, and services..."

Closed record review of Patient #6 revealed a 98 year-old female that presented to the emergency department (ED) on 03/01/2013 at 0213 via ambulance with a chief complaint of fall with facial laceration. Record review revealed the patient had a neurosurgical consult and surgical trauma consult conducted during the ED visit. Review revealed the patient was diagnosed with a closed head injury (subdural hematoma), maxilla and lumbar fractures. Review revealed a 3 centimeter laceration to the scalp was closed and pain medication was administered. Record review revealed a physician's order was placed at 0259 for a "urinalysis with microscopic." Further review of the record revealed no documentation of an attempt to obtain the urine specimen or notification to the physician that the urine was unable to be obtained. Review of the record revealed no physician's order to catherize the patient and no evidence that nursing staff attempted to catherize the patient. Record review revealed the patient was discharged back to a nursing facility at 0924.

Review of a grievance filed by Patient #6's family member on 03/06/2013 revealed the family member was concerned that a urinalysis was not obtained during the patient's ED visit on 03/01/2013 and that "catheter placement after three attempts were unsuccessful." Review of the grievance revealed that the patient was diagnosed with a urinary tract infection after returning to the nursing facility. Review of the investigation by the ED Medical Director revealed "... I do find the order (urinalysis) but I cannot find any documentation of the order being acknowledged... Frankly I believe the UA (urinalysis) was overlooked because of the complexity of her care and the number of consultants required due to her injuries and we simply missed making sure the urine was sent. I can't find any documentation of a catheter placed by nursing in order to obtain... I had a chance to speak with the third year resident who took care of (Patient #6). He tells me the nurses did in deed attempt three times to perform an in and out catheterization with no success...."

Interview on 04/25/2013 at 0910 with the ED physician that provided care to Patient #7 on 03/01/2013 and wrote the order for the urinalysis revealed he remembered the patient. The physician stated the nurses tried to catherize the patient without success and reported to the physician that they were unable to obtain a urine specimen after multiple attempts. The physician stated he canceled the order for urinalysis because he felt it would be too traumatic to continue to try to catherize the patient.

Telephone interview on 04/25/2013 at 1100 with RN #9 revealed she was one of three nurses that provided primary care for Patient #7 during the ED visit on 03/01/2013. The staff member stated she had reviewed the medical record with the ED nursing manager and she was unable to remember this patient. The staff member stated she could not recall catherizing this patient and confirmed there was no documentation of an attempt to catherize the patient. The nurse stated the order for the urinalysis was written at 0259 and the patient was in radiology from 0303 through 0319. The staff member stated "I did not acknowledge the order (for urinalysis)." The nurse revealed RN #10 took over care of the patient at 0343.

Telephone interview on 04/25/2013 at 1110 with RN #10 revealed she was one of three nurses that provided primary care for Patient #7 during the ED visit on 03/01/2013. The nurse confirmed that she assumed care of the patient at 0343 per the record review. The nurse stated she was unable to remember the patient. The nurse stated she should have documented if she attempted to catherize the patient. The nurse confirmed there was no documentation of an attempt to catherize the patient.

Interview on 04/25/2013 at 1030 with RN #11 revealed she was one of three nurses that provided primary care for Patient #7 during the ED visit on 03/01/2013. Interview revealed the nurse assumed care of the patient at 0730 and remained her primary nurse until the patient was discharged. The nurse stated she could not remember the patient. Interview confirmed there was no documentation of an attempt to catherize the patient and no evidence that the physician was notified of the inability to obtain a urinalysis. The nurse reviewed the physician's orders and stated there was no order to catherize the patient.

Interview on 04/25/2013 at 1130 with an ED nursing administrative staff member revealed she had received a grievance about catherizing the patient unsuccessfully during the ED visit on 03/01/2013. The staff member stated she had talked with the Charge Nurse that was working when this patient came into the ED on 03/01/2013 who told her that RN #9 and RN #10 had a hard time catherizing this patient. Interview revealed there should have been an order to catherize the patient and there is no evidence the order was written. The staff member stated there should be documentation by the nurses that attempted to catherize the patient and the outcome of the attempts. Interview revealed there is no documentation of the attempts to catherize the patient. The staff member stated there should be documentation of notification to the physician that the attempts to obtain a urinalysis were unsuccessful and there is no documentation that the physician was notified. The staff member stated "I feel like the attempt to catherize the patient was done." Interview revealed nursing staff failed to document the attempts to catherize the patient and the outcome of the attempts. The staff member stated they failed to follow the hospital policy regarding documentation.

Based on policy and procedure review, medical record review, observations, and staff interviews, the hospital failed to label intravenous tubing for 3 of 3 patients reviewed (#13,#14, #30).

The findings include:

Review of the hospital's policy, "Management of Intravascular Device(s)", revised 07/01/2010 revealed, "...IV (intravenous) administration tubing, including non lipid hyperalimentation and "piggy-back" tubing should be changed every 96 hours."

1. Open medical record review of Patient #13 revealed a 67 year old female, admitted on 04/23/2013 as a code stroke.

Observation on 04/23/2013 at 1400 revealed the IV (intravenous) tubing used to deliver Alteplase (t-PA) (medication used to break down blood clots) to Patient #13 contained no labeling to indicate the date and time of the initial use.

Interview on 04/23/2013 at 1345 with RN #3 revealed the ED (emergency department) follows the hospital policy for the management of IV (intravenous) administration. Interview revealed, "IV (intravenous) tubing should be labeled with date and time upon initiation."

Interview on 04/25/2013 at 0917 with ED (emergency department) manager revealed, "IV (intravenous) tubing should be labeled at initiation and changed every 96 hours per hospital policy." Interview revealed, "we (nursing staff) absolutely need to follow the hospital policy to label IV (intravenous) tubing on initiation and change the tubing every 96 hours." Interview confirmed the hospital nursing staff did not follow the hospital "Management of Intravascular Device(s) policy."

2. Open medical record review of Patient #15 revealed a 65 year old male, admitted on 04/23/2013 with the chief complaint of seizure and hypertension.

Observation on 04/24/2013 at 1340 revealed the intravenous tubing for the administration of Keppra (medication for seizure prevention) 250 mgs (milligrams) IV (intravascular) BID (twice daily) contained no label with date and time of initiation.

Interview with RN #4 revealed Patient #15 received Keppra (a seizure prevention medication) via IV (intravenous route) followed by IV (intravenous) saline bolus for flushing. Interview confirmed there was no evidence of a label attached to the IV (intravenous) tubing to indicate date or time of initiation.

Interview on 04/24/2013 at 1345 with the Neuro Nurse Manager revealed, "There was no evidence of labeling on Patient #15's IV (intravenous) tubing for the administration of Keppra (medication for seizure prevention) 250 mgs(milligrams) IV BID (twice daily). Interview revealed," IV (intravenous) tubing should be labeled and changed every 96 hours." Interview confirmed the hospital nursing staff did not follow the hospital Management of Intravascular Device(s) policy.

3. Open medical record review of Patient #30 revealed an 80 year old male, currently in the ED (emergency department) with the chief complaint of generalized weakness. Medical record review revealed the Patient #30 was assessed to be dehydrated requiring IV (intravenous) therapy.

Observation on 04/25/2013 at 1405 revealed no evidence of labeling IV (intravenous) tubing for the administration of IV fluids

Interview on 04/25/2013 at 1430 with Nurse #6 revealed Patient #30 was receiving IV (intravenous) fluids and there was no evidence of labeling on the IV tubing to indicate date and time of initiation.

Interview on 04/25/2013 at 0917 with ED (emergency department) manager revealed, "IV (intravenous) tubing should be labeled at initiation and changed every 96 hours per hospital policy." Interview revealed, "we (nursing staff) absolutely need to follow the hospital policy to label IV (intravenous) tubing on initiation and change the tubing every 96 hours." Interview confirmed the hospital nursing staff did not follow the "Management of Intravascular Device(s) policy."

NC00077894, NC00078270, NC00078037, NC00078166, NC00079407, NC00079526, NC00083670, NC00084578, NC00085683, NC00087691, NC00087975