HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the grievance process was implemented as evidenced by failing to identify, investigate, and document a patient's formal complaint as a grievance for 1 of 1(#3) patient complaints reviewed out of a total sample of 5 (#1-#5).
Findings:

Review of the hospital policy titled, Patient Complaints/Grievances, Policy No. RI-110 revealed in part the following:
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) 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. If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present and is postponed for later resolution and/or requires investigation and/or requires further actions for resolution, then the complaint is a grievance for the purposes of this policy....
A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs. For the purpose of this policy an e-mail or fax is considered "written"....
Whenever the patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply.


Review of the grievance log for 2017 revealed no documented evidence of a grievance related to Patient #3.

Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted under observation status on 02/14/17 with diagnoses of Chest Pain, Anxiety, Hypertension and Hyperlipidemia. The record revealed the patient presented to the ED with a chief complaint of Chest Pain. The patient was discharged to home on 02/16/17 at 2:01 p.m.

Review of the discharge summary documented by S22Physician on 2/16/17 at 1:18 p.m., revealed the following: "In regards to the patient's admission I would mention that both patient and his wife expressed appropriate concerns regarding issues which were either not addressed in a timely manner, or miscommunicated during this stay. I advised them regarding the appropriate people they should follow up with these concerns. I did apologize for any misunderstanding that may have occurred. In addition in review of his records the patient does qualify for inpatient status. His wife expressed concern that this had not been communicated to them when he was admitted and they were told he was under observation status. He did require a 2 midnight stay to regulate blood pressure as well as to work up further cause of his atrial fibrillation. He is currently stable for discharge and will be seen on follow up with his cardiologist...."

Further review of the patient's medical record revealed no documented evidence of the patient's concerns or issues.

In an interview on 03/09/17 at 2:00 p.m. S12CM Director at Hospital A confirmed she had provided services to Patient #3. S12CM Director stated the staff had questions about the MOON letters and she had provided a MOON letter to this patient. S12CM Director stated Patient #3's wife expressed concerns related to what observation status was and what they would have to pay. She stated the patient and his wife expressed concern that this was not explainedto them in the ED. S12CM Director stated the patient expressed concern that blood thinners were prescribed for him and he had a history of a subdural hematoma. S12CM Director stated the patient did not want to be charged for the medications he had received. S12CM Director stated she could not quote them a list of billables as requested by the patient. S12CM Director stated she called S5Physician who was the patient's attending physician that day, regarding the patient's concerns about his medications. S12CM Director stated the patient wanted a cardiology consult also. S12CM Director stated she immediately escalated this to the patient advocate, S11PA and S23CFO. S12CM Director stated it was documented in an e-mail and stated she could provide that documentation. Confirmed she did not document this patient interaction in the patient's medical record or in the hospital's on-line Occurrence Reporting system. S12CM Director stated she did not know if the patient advocate followed up with the patient. S12CM Director stated she sat down, wrote out their (Patient #3 and spouse) entire concerns, and the spouse read over it and agreed with it. S12CM Director stated she put what she wrote for the wife to read in the email and sent that to S11PA.

In an interview on 03/09/17 at 2:39 p.m., S11PA stated she did not recall receiving an email from S12CM Director related to Patient #3. Stated if a complaint is not handled on the spot, it is put into the on-line Ocurrence Reporting system as a grievance. S11PA stated she also received complaints in person, by phone, mail, and sometimes by e-mail. She stated she entered the complaints she received into the on-line Occurrence Reporting system.

On 03/09/17 at 4:00 p.m., S1CNO provided an e-mail from S12CM Director to S11PA and S23CFO related to Patient #3's complaint. Review of the e-mail chain revealed S11PA forwarded the e-mail to S4Dir Cardiology and S7RN. Review of the e-mail dated 02/16/17 at 4:18 p.m. revealed in part the following:
I, (S12CM Director)....went to a patient's room, Patient #3 to give a MOON letter and the patient/spouse had many complaints. They wished to "file a formal complaint".... Their first complaint was they were not notified of the patient's status in observation. They said they should've been notified in the ED. I answered many questions regarding the observation status, one being that the patient should take his home medications, as Medicare may bill for the medications in observation status. They said they do NOT wish to be billed for any medications prior to the observation notice being given, because they were not aware....
Secondly, they were upset about the length of time it took to be evaluated by a physician-as the patient stated he was admitted at 4:00 p.m., and by 12:00 p.m. the next day, he had not been seen by a cardiologist. Also, the patient was upset about being given new medications-and not having any education on what the medications were. Especially the medications Lovenox and Aspirin, as they are blood thinners, and patient was instructed not to take blood thinners for his history. The blood pressure medication, as well. I did extensive patient teaching on the observation status, the new medications, patient's rights, and contacted the attending physician, S5Physician.....I followed back with the patient and spouse later in the day, and they seemed satisfied. Patient was being discharged, and they clarified with me that I would "file their formal complaint".

In an interview on 03/09/17 at 4:20 p.m., S3Dir Quality confirmed there was no documented evidence of any follow up to this complaint. She stated the staff considered the complaint resolved. After review of the email indicating the patient and wife wanted S12CM Director to file their formal complaint, she confirmed the complaint should have been followed up and confirmed the formal complaint was not handled as a grievance.

In an interview on 03/10/17 at 12:25 p.m., S4Dir Cardiology reviewed the e-mail forwarded from S11PA regarding the complaint from Patient #3. S4Dir Cardiology was asked if any follow-up had been done regarding this complaint. She stated she did follow up with S12CM Director and asked for training/information about the MOON process as they were not familiar with it. Stated she did talk to S7RN about the events of the day on 2/15/17, but it was not documented. She confirmed the patient's wife indicated she wanted the complaint handled as a formal complaint and this should have been entered as a grievance. When asked who was responsible for entering the complaint in the online system, she stated any staff member can enter a complaint and usually it was the person who received the complaint.

Based on record review and interview, the hospital failed to ensure staff identified a formal complaint as a grievance and initiated the grievance process, and failed to ensure, in its resolution of the grievance, the hospital provided the patient with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion for 1 of 1 (#3) patients reviewed with a grievance out of a total sample of 5 (#1-#5).
Findings:

Review of the hospital policy titled, Patient Complaints/Grievances, Policy No. RI-110 revealed in part the following:
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) 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. If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present and is postponed for later resolution and/or requires investigation and/or requires further actions for resolution, then the complaint is a grievance for the purposes of this policy....
A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs. For the purpose of this policy an e-mail or fax is considered "written"....
Whenever the patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply....
Upon receipt of a complaint, the staff present will document the complaint and the actions taken to satisfy the complainant....
Upon receipt of a grievance, the person receiving the grievance shall document the grievance in the online Occurrence Reporting system. Documentation of all follow-up to grievances shall be maintained in the on-line Occurrence Reporting system....
Following completion of the investigation, the patient, and/or their representative will be provided with written notice of the hospital's decision including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.


Review of the grievance log for 2017 revealed no documented evidence of a grievance related to Patient #3.

Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted under observation status on 02/14/17 with diagnoses of Chest Pain, Anxiety, Hypertension and Hyperlipidemia. The record revealed the patient presented to the ED with a chief complaint of Chest Pain.

Review of the discharge summary documented by S22Physician on 2/16/17 at 1:18 p.m., revealed the following: "In regards to the patient's admission I would mention that both patient and his wife expressed appropriate concerns regarding issues which were either not addressed in a timely manner, or miscommunicated during this stay. I advised them regarding the appropriate people they should follow up with these concerns. I did apologize for any misunderstanding that may have occurred. In addition in review of his records the patient does qualify for inpatient status. His wife expressed concern that this had not been communicated to them when he was admitted and they were told he was under observation status. He did require a 2 midnight stay to regulate blood pressure as well as to work up further cause of his atrial fibrillation. He is currently stable for discharge and will be seen on follow up with his cardiologist...."

Further review of the patient's medical record revealed no documented evidence of the patient's concerns or issues.

In an interview on 03/09/17 at 2:00 p.m. S12CM Director at Hospital A confirmed she had provided services to Patient #3. S12CM Director stated after she provided the patient with a MOON letter, Patient #3's wife expressed concern on what observation status was and what they would have to pay. She stated the patient and his wife expressed concern that this was not explained in the ED. S12CM Director stated the patient expressed concern that blood thinners were prescribed for him and he had a history of subdural hematoma. S12CM Director stated the patient did not want to be charged for the medications he had received. S12CM Director stated she called S5Physician who was the patient's attending physician that day, regarding the patient's concerns about his medications. S12CM Director stated the patient wanted a cardiology consult also. S12CM Director stated she immediately escalated this to the patient advocate, S11PA and S23CFO. S12CM Director stated it was documented in an e-mail and stated she could provide that documentation. Confirmed she did not document this patient interaction in the patient's medical record or in the hospital's online Occurrence Reporting system. S12CM Director stated she did not know if the patient advocate followed up with the patient. S12CM Director stated she sat down, wrote out their (Patient #3 and spouse) entire concerns, and the spouse read over it and agreed with it. S12CM Director stated she put what she wrote for the wife to read in the email and sent that to S11PA.

In an interview on 03/09/17 at 2:39 p.m., S11PA stated she did not recall receiving an email from S12CM Director related to Patient #3. Stated if a complaint is not handled on the spot it is put into the on-line Occurrence Reporting system as a grievance. S11PA stated she also received complaints in person, by phone, mail, and sometimes by e-mail. She stated she entered the complaints she received into the on-line Occurrence Reporting system.

On 03/09/17 at 4:00 p.m., S1CNO provided an e-mail from S12CM Director to S11PA and S23CFO related to Patient #3's complaint. Review of the e-mail chain revealed S11PA forwarded the e-mail to S4Dir Cardiology and S7RN. Review of the e-mail dated 02/16/17 at 4:18 p.m. revealed in part the following:
I, (S12CM Director)....went to a patient's room, Patient #3 to give a MOON letter and the patient/spouse had many complaints. They wished to "file a formal complaint".... Their first complaint was they were not notified of the patient's status in observation. They said they should've been notified in the ED. I answered many questions regarding the observation status, one being that the patient should take his home medications, as Medicare may bill for the medications, in observation status. They said they do NOT wish to be billed for any medications prior to the observation notice being given, because they were not aware....
Secondly, they were upset about the length of time it took to be evaluated by a physician-as the patient stated he was admitted at 4:00 p.m., and by 12:00 p.m. the next day, he had not been seen by a cardiologist. Also, the patient was upset about being given new medications-and not having any education on what the medications were. Especially the medications Lovenox and Aspirin, as they are blood thinners, and patient was instructed not to take blood thinners for his history. The blood pressure medication, as well. I did extensive patient teaching on the observation status, the new medications, patient's rights, and contacted the attending physician, S5Physician.....I followed back with the patient and spouse later in the day, and they seemed satisfied. Patient was being discharged, and they clarified with me that I would "file their formal complaint".

In an interview on 03/09/17 at 4:20 p.m., S3Dir Quality confirmed there was no documented evidence of any follow up to this complaint. She stated the staff considered the complaint resolved. After review of the email indicating the patient and wife wanted S12CM Director to file their formal complaint, she confirmed the complaint should have been followed up and confirmed the formal complaint was not handled as a grievance. S3Dir Quality confirmed there was no documentation of an investigation and there was no written response sent to the patient.

In an interview on 03/10/17 at 12:25 p.m., S4Dir Cardiology reviewed the e-mail forwarded from S11PA regarding the complaint from Patient #3. S4Dir Cardiology was asked if any follow-up had been done regarding this complaint. She stated she did follow up with S12CM Director and asked for training/information about the MOON process as they were not familiar with it. Stated she did talk to S7RN about the events of the day on 2/15/17, but it was not documented. She confirmed the patient's wife indicated she wanted the complaint handled as a formal complaint and this should have been entered as a grievance. When asked who was responsible for entering the complaint in the online system, she stated any staff member can enter a complaint and usually it was the person who received the complaint.

30172

Based on record reviews and interviews the hospital failed to ensure that the exercise of Patient's Rights requirement was met as evidenced by failing to inform patients admitted as Observation Admit Status patients of their right to supply their own prescribed medications from home for use in the hospital to be administered by the nursing staff when those prescribed medications were ordered by their attending physicians in the hospital setting for 1 (#4) patient out of a sample of 5 patients.

Findings:

Review of the hospital policy titled Patients' Rights and Responsibilities, Policy No. RI-010, revealed in part the following: The patient has the right to be informed of the hospital's charges for services and available payment methods. The patient has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known.

A review of the Medicare Outpatient Observation Notice (MOON) form, as provided by the hospital to all Observation Admit Status patients revealed in part: Your costs for medications: Generally, prescription medications you get in a hospital outpatient setting are not covered by Part B Medicare. These medications are medications you normally take on your own at home. For safety reasons, many hospitals do not allow you to take medications brought from home. You would likely need to pay out-of-pocket for these "home" medications if ordered for you by your physician in the hospital setting.

Patient #4
The patient was a 66 year old male with a medicare plan and was admitted from the ED as an OBS patient on 03/08/17 at 3:11 p.m. with an admit diagnosis of chest pain. A review of the admit orders revealed the patient was admitted as an Observation Admit Status patient. A review of the Case Manager notes by S13CM revealed the patient was given the Medicare Outpatient Observation Notice (MOON) form and that the patient signed the form on 03/09/17 at 10:00 a.m.

In an interview on 03/09/17 at 4:00 p.m. with Patient #4 he indicated that S13CM explained the MOON form to him, but he was not given the option of supplying his own medications from home (that were also being administered to him in the hospital). The patient indicated that he was told that the hospital preferred to provide (administer) any of his home medications from the hospital pharmacy and that he may be responsible for these medications out-of -pocket.

In an interview on 03/09/17 at 2:00 p.m. with S13CM she indicated that she discussed with Patient #4 the Medicare Outpatient Observation Notice (MOON), including the "Your Costs for Medications" section, and had the patient sign the form since he was an Observation Admit Status patient and had Medicare. S13CM indicated that patients on Observation Admit Status and on Medicare would be responsible for their deductibles and their co-pay and all their (home based) medications that they was given in the hospital setting as an Observation Admit Status patient, unless the patient provided his own home medications. The hospital would then get the physician to write an order for the patient's home medicines to be administered to the patient by the hospital nursing staff while in the hospital. Any new medicines ordered for the patient would be paid for by their Medicare plan. If the hospital administered medicines that the patient normally took at home, then the patient may be responsible for their costs and only new medicines ordered would be paid by Medicare. S13CM indicated that her supervisor, S22CM, preferred the Case Managers to tell the Observation Admit Status patients that the hospital preferred to administer (home) medicines dispensed from the hospital pharmacy as opposed to having the patients bring their home medicines from home for use in the hospital setting.

In an interview on 03/10/17 at 11:30 a.m. with S22CM she indicated that she has never told her Case Managers to tell Observation Admit Status patients that the hospital preferred to administer (home) medicines dispensed from the hospital pharmacy, as opposed to the patients bringing their home medicines from home for use in the hospital setting. She indicated that it was probably a miscommunication.

30172

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient that included all the patient's current medical diagnoses for which the patients were being treated and not solely those needs relating to the admitting diagnosis for 4 (#2, #3, #4, #5) of 5 (#1-#5) sampled patient medical records reviewed for nursing care plans.

Findings:

A review of the hospital policy titled, "Assessment/Reassessment in Planning and Interdisciplinary Coordination of Care Plan", Policy No. PC-033, as provided by S10RN as the most current, revealed in part:
D. Interdisciplinary Functional Assessments/Plan of Care:
2. This record will be initiated by a RN upon hospital admission and will be reviewed and updated every shift as new problems are identified and current problems are resolved.
3. The nurse will consult interdisciplinary team members for identified patient problems....
4. The consulted discipline/individual is responsible for reviewing and updating the Interdisciplinary Care Plan on an ongoing basis as appropriate for that discipline.

Patient #2
The patient was a 66 year old female admitted from the ED as an OBS patient on 03/08/17 at 12:29 p.m. with a chief admit diagnosis of chest pain. Other current diagnoses as noted in the attending physician's H&P were as followed in part: GERD, HTN, Hyperlipidemia, Diabetes, ESRD, Pulmonary Edema, Chronic Anemia, and Depression. A review of the patient's MAR revealed the patient was ordered the following medications in part: Lipitor, Coreg, Catapres, Cymbalta, Epogen, Apresoline, Cozaar, Lopressor, Procardia, Nitro, Protonix, Desyrel, and Xanax and was on a Sliding Scale for Diabetes.

A review of the patient's care plan on 03/10/17 at 11:45 a.m. revealed a care plan for Pain/Comfort and Respiratory Function only. A further review of the patient's care plan revealed no documented evidence of care plans for the following patient's current medical conditions: HTN, GERD, ESRD, Depression, and Diabetes.

In an interview on 03/10/17 at 11:45 a.m. with S15RN, supervisor for the patient's unit, she indicated that the patient was not care planned for her other current medical diagnoses as listed by the physician to include: HTN, GERD, ESRD, Depression, and Diabetes. She indicated that the patient should have been care planned for her other current conditions that were being treated. S15RN further indicated that the patient's care plan was not comprehensive and did not include all of the patient's current medical diagnoses. S15RN indicated that the care plans initiated by the admit RNs could be updated by any nurse


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted from the ED as an observation patient on 02/14/17 at 5:21 p.m. with an admitting diagnosis of Chest Pain Atypical, Anxiety, Atrial Fibrillation, Hypertension, and Hyperlipidemia.

Review of the patient's record revealed Hydralazine (medication for high blood pressure) was a new medication ordered to treat the patient's Hypertension and the patient required an additional night hospital stay to stabilize his blood pressure.

Review of the nurse's documentation revealed on 02/15/17 the patient was anxious, restless, uncooperative, and had received a new order for Zofran (anti-nausea) medication. The record revealed the patient received an injection of Zofran 4 mg on 02/15/17 at 9:51 p.m.

Review of the patient's plan of care revealed the only problem/goal/intervention identified on the care plan was pain.

In an interview on 03/10/17 at 9:17 a.m., S10RN (Administrative Supervisor/Education Coordinator) confirmed pain was the only problem identified on the patient's care plan. S10RN confirmed the patient was being treated for Hypertension and that was why the patient was kept an additional day in the hospital. S10RN confirmed the patient also had anxiety and nausea that required PRN medication and these problems were not included in the plan of care.


Patient #4
The patient was a 66 year old male admitted from the ED as an OBS patient on 03/08/17 at 3:11 p.m. with a chief admit diagnosis of chest pain. Other current diagnoses as noted in the attending physician's H&P were as followed in part: Arthritis, Cholelithiasis, GERD, Hyperlipidemia, Diabetes, CAD, and HTN. A review of the patient's MAR revealed the patient was ordered the following medications in part: Norvasc, Aspirin, Liorseal, Plavix, Lovenox, Neurotin, Glucotrol, Hydrochlorothiazide, Novolin R, Metaformin, Lopressor, Protonix, Crestor, and Diovan and was on a Sliding Scale for Diabetes.

A review of the patient's care plan on 03/09/17 at 2:30 p.m. revealed a care plan for Pain/Comfort only. A further review of the patient's care plan revealed no documented evidence of care plans for the following patient's current medical conditions: Arthritis, Cholelithiasis, GERD, Hyperlipidemia, Diabetes, CAD, and HTN.

In an interview on 03/09/17 at 2:45 p.m. with S17RN, charge nurse for the patient's unit, and S19RN, caring for the patient, they indicated that the patient was not care planned for his other current medical diagnoses as listed by the physician to include: Arthritis, Cholelithiasis, GERD, Hyperlipidemia, Diabetes, CAD, and HTN. S19RN indicated that the patient should have been care planned for his other current medical conditions that were being treated. S19RN further indicated that the patient's care plan was not comprehensive and did not include all of the patient's current medical diagnoses. S17RN indicated that the care plans initiated by the admit RNs could be updated by any nurse.


Patient #5
The patient was an 82 year old male admitted from the ED as an OBS patient on 03/08/17 at 9:15 p.m. with a chief admit diagnosis of chest congestion and pain. Other current diagnoses as noted in the attending physician's H&P were as followed in part: Arthritis, Congestive Heart Failure, Hyperlipidemia, Diabetes, CAD, Obesity, Atrial Fibrillation, and HTN. A review of the patient's MAR revealed the patient was ordered the following medications in part: Aspirin, Lotensin, Coreg, Lanoxin, Novolog, Lantus, Xalatan, Theragran, Tamiflu, Zocor, Aldactone, Demadex, and Coumadin. The record revealed the patient was on an Insulin Sliding Scale for Diabetes.

A review of the patient's care plan on 03/09/17 at 2:30 p.m. revealed a care plan for Alteration in Cardiac Function, Respiratory Function, Pain/Comfort, and Risk for Infection only. A further review of the patient's care plan revealed no documented evidence of care plans for the following patient's current medical conditions: Diabetes and HTN.

In an interview on 03/10/17 at 10:45 a.m. with S17RN, charge nurse for the patient's unit, and S14RN, caring for the patient, they indicated that the patient was not care planned for his other current medical diagnoses as listed by the physician to include: Diabetes and HTN. S14RN indicated that the patient should have been care planned for his other current medical conditions that was being treated. S14RN further indicated that the patient's care plan was not comprehensive and did not include all of the patient's current medical diagnoses. S17RN indicated that the care plans initiated by the admit RNs could be updated by any nurse.