HospitalInspections.org

Based on patient handbook review and staff interview the facility failed to inform each patient whom to contact to file a grievance by providing the incorrect phone number.

FINDINGS:

Patient handbook revealed "...The Mississippi Department of Health is also available to assist you with any question, concern, or grievance by calling 601-576-7400." (The correct number is 1-800-227-7308).

These findings were confirned during an interview with the Chief Quality Officer on 07/01/10 at approximately 3:00 p.m. No additional documentation was provided.

Based on policy review and complaint documentation, the facility failed to provide a timely review and response of a grievance for one (1) of one (1) patient, Patient #1.

FINDINGS:

Policy review "Patient Greievance" revealed "...Any patient grievance should be directed to the Department Head or Department Director. An explanation should also be given to the patient (or his represenative), stating that he may contact the President by calling 288-7000 (Extension 8-4201) or by writing to the Office of the President. Patient grievances will be referred for follow up to the Patient Advocate, who reports directly to the President. After normal office hours, the patient (or his respresenative) may call 8-2255 for referral to the Patient Care Supervisor...".

During an interview with the Chief Quality Officer on 07/01/10 at approximately 3:00 p.m., he/she stated that the attorney for the facility had advised them not to provide a written response to Patient #1.

Based on staff interview the facility failed to provide the patient with a written response of its grievance solution process for one (1) of one (1) patient, Patient #1.

FINDINGS:

During an interview with the Chief Quality Officer on 07/01/10 at approximately 3:00 p.m. he/she stated that the attorney for the facility had advised them not to provide a written response to Patient #1.

Based on medical record review and staff interview the facility failed to provide safe, efficient and therapeutic nursing care consistent with the professionally recognized standards of nursing practice for one (1) of one (1) patient, Patient #1.

FINDINGS:

Medical record review for Patient #1 revealed she was admitted to the facility on 06/29/09 with Preganancy Induced Hypertension (PIH). Discharge date was 07/09/09.

Admisson orders on 06/29/09 do not indicate the time of the order but include...Notify MD of sys BP>160/DBP>110 (BP=Blood Pressure). On 07/06/09 at 4:37 a.m. BP was 175/94. It was not documented as being reported to the physician.

Clinical record review for Patient #1 revealed that a consent form was signed upon admission 06/29/09 for Vaginal Delivery of infant. The consent was not dated by the physician. Physician's orders on 07/07/09 at 0505 included "Sign consent for: Cesarean Section." A consent form was not obtained for the Cesarean Section procedure that was performed on 07/07/09.

Nursing documentation on 07/08/09 at 1923 revealed "...perineum clean episiotomy is free of edema...pulse 120, BP 144/96, No edema...". Patient was status post cesarean section. She did not have an episiotomy.

Nursing documentation on 07/08/09 at 0359 revealed "...No edema...Intake and Output Urine 900 ml. Characteristics: foley yellow urine...0804 Urine Pattern: voiding without complaints of pain, frequency or incontinence...1539 Urine 1000 ml Characteristics: voided-yellow urine...". There was no documentation of physician's orders to remove the foley or nursing documentation of time or removal of foley.

Nursing documentation on 07/09/09 at 0718 revealed "edema: bilateral lower extremities bilateral upper extremities....0728 Peripheral IV Removal...removed without complications...". Edema not reported to physician. No physician's order to remove peripheral IV (Intravenous Access).

Nursing documentation on 07/09/09 at 0902 revealed "Discharge Instructions...New prescriptions: given to patient...". There is no documentation of discharge planning or instructions prior to discharge. There is no explanation of new prescriptions given to patient.

Physician's Post-Op Orders-Cesarean Section on 07/07/09 included...Notify MD if HR less than 60 or greater than 120...(HR=Heart Rate). Vital Sign documentation on 07/09/09 at 0755 HR 122...1012 HR 122...1130 HR 123. There is no documentation to reveal that the physician was notified of the elevated Heart Rate.

These findings were discussed with the Patient Care Manager, Director of Women/Children's Services, Director of Clinical Operations and Chief Quality Officer during the exit conference on 07/01/10. No additional documentation was provided.

Based on clincal record review and staff interview the facility failed to ensure that all entries were complete, authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the service(s) furnished for one (1) of one (1) patient, Patient #1.

FINDINGS:

Review of the clinical record for Patient #1 revealed admission orders on 06/29/09 do not indicate the time of the order.

A consent form signed upon admission 06/29/09 for Vaginal Delivery of infant. The consent was not dated by the physician. Physician's orders on 07/07/09 at 0505 included "Sign consent for: Cesarean Section." A consent form was not obtained for the Cesarean Section procedure that was performed on 07/07/09.

These findings were discussed with the Patient Care Manager, Director of Women/Children's Services, Director of Clinical Operations and Chief Quality Officer during the exit conference on 07/01/10. No additional documentation was provided.

Based on clincal record review and staff interview the facility failed to ensure that a properly executed consent form for operation was in the patient's chart prior to surgery for one (1) of one (1) patient, Patient #1.

FINDINGS:

Clinical record review for Patient #1 revealed Physican's orders on 07/07/09 at 0505 included "Sign consent for: Cesarean Section." A consent form was not obtained for the Cesarean Section procedure that was performed on 07/07/09.

These findings were discussed with the Patient Care Manager, Director of Women/Children's Services, Director of Clinical Operations and Chief Quality Officer during the exit conference on 07/01/10. No additional documentation was provided.

Based on clinical record review and staff interview the facility failed to provide post-op discharge planning for one (1) of one (1) patient, Patient #1.

FINDINGS:

Clinical record review for Patient #1 revealed an admission date of 06/29/09 and discharge date of 07/09/09. There was no documentation that included post-op discharge planning. There was no documentation of discharge plans in the physician's progress notes until the day of discharge 07/09/09. There is no physician's order for discharge.

These findings were discussed with the Patient Care Manager, Director of Women/Children's Services, Director of Clinical Operations and Chief Quality Officer during the exit conference on 07/01/10. No additional documentation was provided.

Based on policy review, clinical record review and staff interview the facility failed to properly obtain a written informed consent for one (1) of one (1) patient, Patient #1.

FINDINGS:

Policy review "Informed Consent Policy" revealed "Physicians' Responsibility: Informed consent is an educational process and information exchange that takes place between a physician and a patient about a medical procedure or treatment. It is the physician's legal responsibility to obtain informed consent from the patient. Information to be disclosed and discussed with the patient...The informed consent must be documented in the patient's medical record or on the form appended to the record and to include the following information: A. Patient identity. B. Date when patient informed and date when patient signed the form, if different. C. Nature of the procedure or treatment proposed to be rendered. D. Name of the individual who will perform the procedure or administer the treatment. E. Authorization for any required anesthesia.

Clinical record review for Patient #1 revealed that a consent form was signed upon admission on 06/29/09 for Vaginal Delivery of infant. The consent was not dated by the physician. Physician's orders on 07/07/09 at 0505 included "Sign consent for: Cesarean Section." A consent form was not obtained for the procedure.

These findings were discussed with the Patient Care Manager, Director of Women/Children's Services, Director of Clinical Operations and Chief Quality Officer during the exit conference on 07/01/10. No additional documentation was provided.