HospitalInspections.org

Based on record review and interview the hospital failed to establish and implement a process for prompt resolution of patient grievances as evidenced by:
1.) failing to ensure its grievance process provided prompt resolution of patient grievances for 3(#3, #R2, #R3) of 4 (#3, #R1, #R2, #R3) grievances reviewed, and 2.) failing to inform each patient whom to contact to file a grievance.
Findings:

1). Failing to ensure its grievance process provided prompt resolution of patient grievances:

Review of hospital policy titled, "Grievance Process", # A-110, revised 10/10 and provided by S1Regulatory Coordinator as current, revealed the following, in part:
Purpose: To provide/maintain a timely, reasonable, and consistent grievance process in which prompt resolution to patient/patient representative grievances is achieved.
Policy: ...4. BRGMC (Baton Rouge General Medical Center) will review, investigate, each grievance within a reasonable time frame... 5. A written response is sent to the patient/patient representative within 7-10 days from the time the Grievance Manager is notified...
Procedure: 1. Any staff member receiving a complaint will attempt to resolve it immediately beginning with the patient care staff. If the situation cannot be immediately resolved, it is directed to the Grievance Manager, documented in the incident reporting system, and reviewed by the Grievance Committee.
2. Upon receipt of grievance, if it has not been entered into the incident reporting system, it is done at this time.
4. Should the grievance require more extensive investigation, an initial letter will be sent to the patient/patient representative notifying him/her that grievance process is underway.
5. Grievance Manager works with all involved units and departments and/or the AOC to investigate by gathering and reviewing information from interviews and the medical records. Based on the investigative findings, the Grievance Manager ensures that appropriate actions are taken to resolve the patient's grievance.
6. The Grievance Manager ensures that each designated Manager/Director follows up with his/her portion of the investigation in a timely, reasonable, and consistent manner. Each week, an open file review is completed and any Manager/Director with outstanding items receives reminder notifications.
7. Once all designated Managers/Directors have satisfactorily addressed the grievance, the case is closed and the Grievance Manager prepares a letter informing the patient/patient representative of the grievance process and outcome of the investigation.


Patient #3
Review of the grievance log for October 2013 revealed no documented evidence of a grievance regarding Patient #3.

In a face-to-face interview on 12/26/13 at 3:00 p.m., S2Grievance Coordinator and S3Director of Risk Management were asked if they had received a complaint regarding Patient #3, S2Grievance Coordinator stated she did recall a grievance involving Patient #3. When informed the grievance for Patient #3 was not on the grievance log provided, S2Grievance Coordinator reviewed the electronic record and stated the the incident was in September 2013 and the investigation was completed on 11/21/13. S2Grievance Coordinator reported the mother of Patient #3 called on 11/07/13 and voiced a complaint. When asked who the patient's mother voiced the complaint to, S2Grievance Coordinator stated she was unable to say who the patient's mother spoke to. S2Grievance Coordinator stated the system allowed anonymous reporting and the person taking the call could be anonymous. S3Director of Risk Management verified the system provided for anonymous reporting and the staff member taking the patient's complaint/grievance was not required to enter their name or the date/time of the contact. Documentation of the grievance for Patient #3 was requested for review.

In a telephone interview on 12/27/13 at 11:34 p.m. S8Staff Attorney stated she remembered a family member of Patient #3 coming to her office to complain. S8Staff Attorney stated she could check her email documentation for specific dates/times. S8Staff Attorney then stated on 10/28/13 the mother of Patient #3 came to her office. S8Staff Attorney stated she spoke with the patient's mother because S2Grievance Coordinator was not there at the time. S8Staff Attorney stated the patient's mother was very unhappy with the care her daughter received on the floor. S8Staff Attorney stated the mother reported the nursing staff had not turned her daughter and her wound had opened up. S8Staff Attorney stated she apologized to the patient's mother and gave the mother her card. S8Staff Attorney also stated the patient's mother had informed her she had called previously (prior to 10/28/13) and voiced her complaint and no one responded. S8Staff Attorney stated she asked around her office to see if anyone else had spoken to the patient's mother and found that the patient had spoken with S24Risk Management Assistant and voiced her complaint. S8Staff Attorney stated she documented the mother's complaint in an email and sent the email along with the complaint documented by S24Risk Management Assistant to S2Grievance Coordinator the same day (10/28/13). S8Staff Attorney stated she was contacted by the patient's mother on 11/07/13 and the patient's mother stated she had not heard anything from S2Grievance Coordinator regarding her complaint. S8Staff Attorney stated she contacted S2Grievance Coordinator and she offered no explanation of why the complainant was not contacted. S8Staff Attorney stated she sent the emails to S2Grievance Coordinator again. The email documentation of the patient's mother's complaint were requested for review.

On 12/27/13 at 12:30 p.m. the requested emails and grievance documentation for Patient #3 were provided for review.
Review of the email documentation by S8Staff Attorney to S2Grievance Coordinator dated 10/28/13 at 1:15 p.m. revealed in part the following:
Mother of Patient #3 came in today looking for you and demanded to speak with someone. I went up front and met with her. She was very irritated and upset that no one has called her back. Apparently she launched a "complaint" back with S24Risk Management Assistant on 10/17/13 (attached) and feels that we should have been in touch with her by now. The report she gave me was very consistent with the attached complaint she gave S24Risk Management Assistant so I'm forwarding all the information to you for tracking purposes....Patient #3 was admitted to BRGMC on September 25th for the colostomy reversal. She was in the ICU until September 30th when she was released to the regular floor. Although the patient's mother found the care in ICU to be great, she does not feel that Patient #3 was given good care by the nursing staff once out on the floor. Group Home "D" provided a sitter service for her while she was in our care. She was discharged back to Group Home "D" on October 7th, using her own wheelchair and transported by a transport van owned by Group Home "D". Once back at Group Home "D" a full assessment was performed by their in-house medical staff. It was found that the wound had reopened. A nurse named ____ with Group Home "D" called the BRGMC charge nurse on October 8th to complain that the wound had reopened and no one from BRGMC had notified them of that nor did the discharge paperwork address the issue. I asked her if she had ever noticed the dressing on the wound needing changed and she said that she could not see it when she visited and patient could not feel whether it would have been wet. However she was adamant that S14Surgeon would never have discharged her if the wound was open. She thinks that our nursing staff neglected to tell S14Surgeon the status of the wound and neglected to take proper care of her daughter. She stated her daughter is now back to step one with the wound care at Group Home "D" and she is going to have to undergo care with the wound-vac again just like 2 years ago. She was very upset at this prospect and blames it on the "poor care" given at our facility. She demanded that we look into this immediately and let her know what went wrong and what we plan to do about it. I assured her that we would be initiating an investigation and you would be in touch with her as soon as possible. I asked for her to allow you one week to contact her as we are very busy and you are only one person. She stated she was fine with that.
The mother's name, address and telephone number were included at the bottom of the email.

Review of the attached documentation from S24Risk Management Assistant revealed the following: Mother of Patient #3 called 10/17/13 at 9:45 a.m. (Mother's telephone number listed). Patient #3 came in for surgery for a colostomy reversal on 09/25/13 and was discharged on 10/07/13. She was in ICU until 9/30 and was moved to Unit "A". The complaint is she had the colostomy put in 3 years ago for a wound that would not heal and had the reversal because the wound had closed up and healed. When she was returned to Group Home "D" the wound had reopened. No one from BRGMC disclosed this information. She was supposed to be turned every 2 hours. She feels that the nursing staff did not do their job. Now since the wound has reopened, she is being given wound care at Group Home "D".

Review of the grievance investigation for Patient #3 revealed in part the following:
Incident date: 09/30/13
Discovered date: 11/07/13
Entered date: 11/08/13

Incident Description: Patient #3 - Patient's mother called stating Patient #3 came in for surgery for a colostomy reversal on 09/25/13 and was discharged on 10/07/13. She was in ICU until 9/30 and was moved to Unit "A". The complaint is she had the colostomy put in 3 years ago for a wound that would not heal and had the reversal because the wound had closed up and healed. When she was returned to Group Home "D" the wound had reopened. No one form BRGMC disclosed this information. She was supposed to be turned every 2 hours. She feels that the nursing staff did not do their job. Now since the wound has reopened, she is being given wound care at Group Home "D".

Incident Action Plan:
S2Grievance Coordinator - received date 11/08/13, complete, Last Update; 12/26/13. 11/08/13 File set up. I contacted patient's mother and apologized that I have been out of the office, explained that the investigation had been started. 11/11/13 Reviewed. Letter #1-11/18/13 Reviewed. Awaiting S15Unit Manager 11/25/13 Reviewed. Assessment completed. Letter #2 Case Closed.
S3Director Risk Management - Reviewed. Last update 12/20/13.
S15Unit Manager - Date received: 11/08/13, Complete: 11/21/13. In regards to the sacral wound opening, I cannot find any clear documentation that this occurred. We do have documentation that the patient had a healing stage III/IV to coccyx as documented by ET (Enterostomal) nurse. From documentation, I can see that the patient was placed in her wheelchair per MD (physician) request and chair several times throughout stay. It is documented that the patient was repositioned and turned but was not 100% documented and there are occasions that the patient/sitter refused. Skin assessment was completed every shift. We were not 100% compliant in documentation of turning every 2 hours, so I will reeducate staff in the upcoming meeting and ongoing.

Review of an email attached to the grievance documentation revealed the following: From S4Grievance Coordinator to S1Regulatory Coordinator and S3Director Risk Management, dated 12/26/13. "It appears that Patient #3's mother did make contact with someone on 10/17/13, however that person was not me and for some reason that information was not entered in Qstatim (software), or if it was entered it was not saved under grievance. On October 28th the patient's mother came by our office and demanded to speak to me or someone so S8Staff Attorney met with her and took down the information. I was out of the office for a few days but did hear from S8Staff Attorney that the patient's mother had been by. On November 7th the complaint was entered in Qstatim, I began working on it on November 8th, the investigation was completed on November 25th, 2013...."

In a face-to-face interview on 12/30/13 at 3:45 p.m. S3Director Risk Management verified the grievance regarding Patient #3 was not promptly resolved. S3Director Risk Management stated everyone in his department thought someone else was taking care of it. S3Director of Risk Management stated he was the back up for S2Grievance Coordinator. S3Director Risk Management stated there was no one contact point for patient grievances at this time. S3Director Risk Management stated the problem is in getting the complaint to S2Grievance Coordinator.

#R2
Review of a grievance investigation for Patient #R2 revealed, in part, the following documentation:
Incident Date: 11/23/13 5:00 p.m.
Discovered Date: 11/23/13 5:00 p.m.
Entered Date: 11/24/13 2:45 a.m.
Status: Open

Incident Description:
Son (also a hospital employee) of #R2 was unhappy that his mother's wound care had not been done. He went to central supply requested and obtained the specific dressing needed and return(ed) to the unit.

Incident Action Plan:
S2, Grievance Coordinator: Received 11/25/13, last Update 12/28/13
11/26/13: Reviewed. File set up. Letter #1 Attempted to reach (patient's son). Discussed with (Director of Risk Management) this should be discussed with employee manager. Voicemail left for manager 12/2/13. Reviewed. Awaiting discussion with manager. 12/28/13 reviewed.
S19, Unit Manager: date received- 11/24/13 2:45 a.m., complete-11/25/13 9:11 a.m.
Wound care was ordered daily and he was told by the charge nurse that the dressing could be done anytime within the 24 hours. The charge nurse had already ordered the dressing from central supply and she, as the nurse, was going to do the dressing. "Please make sure (employee name) gets this [incident] report because the DON agrees that he (patient's son and hospital employee) shouldn't have been able to get a dressing from Central (central supply) because the nurse was going to do it plus she had already ordered the dressing."

In an interview 12/30/13 at 4:05 p.m. S3Director Risk Management reported that this grievance was still open because the patient's son was an employee of the hospital and had been able to obtain supplies from Central Supply for his mother's wound care. He further explained that he should not have been able to obtain these supplies from Central Supply himself and that this had not been resolved. When asked if the son's being able to obtain the supplies directly from Central Supply was part of his grievance, S3Director Risk Management said, "No." When asked if he considered this grievance to be processed in a prompt or timely manner, S3Director Risk Manager responded, "No."

#R3
Review of a grievance investigation revealed, in part, the following:
Incident Date: 11/14/13
Discovered Date: 12/13/13
Entered Date: 12/20/13 9:46 a.m.
Status: Open

Incident Description:
"Patient came to ER... by ambulance 11/14/13 with congestive heart failure. He was admitted and had a cyst on his back, which they removed. He was discharged 12/13/13 and when he arrived home by ambulance, his wife said his backside was ripped up and there was a hole where the cyst had been removed which had to be stuffed with gauze. The social worker and nurses told his wife that he needed to be put in a nursing home because she would not be able to care for him. Wife said he got no wound care at the hospital and he doesn't need to be put in a nursing home to die. He needs to be put in a wound care facility which they did not offer."

Incident Action Plan:
S7, Director of Care Management: received-12/20/13 4:07 p.m., complete-12/30/13
"A discharge assessment was completed on the acute floor (location) prior to transfer to SNF (Skilled Nursing Facility). The pt (patient) had HH (home health) with (name of HH agency). The pt was receiving wound care while in the hospital. The documentation by the sw (social worker) notes that the physician felt the pt to be unsafe to dc (discharge) home. The sw (Social Worker) spoke to the wife about nursing home placement as recommended by the physician but she was adamant about him returning home with her. The pt eventually transferred to SNF for continued iv (intravenous) abx (antibiotics) and wound care prior to dc. The pt was on SNF for 3 days. He had orders to resume HH with PT/OT (Physical Therapy/Occupational Therapy) and wound care. The wife was in agreement. HH was set up with (name of HH agency) by the SNF social worker. The orders were faxed to the HH agency including wound care orders.
S2, Grievance Coordinator: received 12/20/13 9:46 a.m., last review 12/29/13 4:37 p.m.
status: open. "12/20/13-Reviewed. File set up. 12.26.13- Awaiting MSS (Medical Staff Services). Letter #1 12/29/13 Reviewed"
Other personnel noted under the Incident Action Plan included:
The Medical Staff Services representative (received 12/20/13, last update: 12/24/13, status: open),
Director of Risk Management (received 12/20/13, last updated 12/23/13, status: complete),
Director for SNF services (received 12/20/13, last updated 12/20/13, status: complete),
Manager of SNF (received 12/20/13, last updated 12/20/13, status: complete), and
S3, Director of Risk Management (received 12/20/13, status: open)

An interview was conducted 12/30/13 at 4:05 p.m. with S3Director Risk Management. After review of grievance investigation documentation regarding Patient #R3, S3Director Risk Management verified that the documented discovery date was 12/13/13 but the grievance was not entered into the system until 12/20/13. When asked what the discovery date represented, S3Director Risk Management reported that he could not determine from the document what exactly the discovery date represented. S3Director Risk Management verified that the grievance was documented with an entry date into the system of 12/20/13, seven (7) days after the discovery date. The Director of Risk Management also verified the date of an acknowledgement letter to the patient, not his wife who lodged the grievance, dated 12/26/13. When asked if he considered the timelines of this grievance as being timely or prompt, he agreed that they were not.
S3Director Risk Management verified that employees could enter a grievance into electronic system, but there was no way to ensure that all grievances were entered, and referred to the Grievance Manager as per the hospital policy.


2) Failing to inform each patient whom to contact to file a grievance.

Review of a pamphlet provided by the hospital to patients on admission included Patient Rights and Responsibilities. Further review revealed, in part, the following under Patient's Rights: "You have the right to information regarding your care which includes:....
* Lodging a concern of grievance about care or service.
(Campus C) Administration: 387-7767
(Campus B) Administration: 763-4040
* Receiving a written response to your grievance within 7-10 days.
The licensing agency for our facility is:
Louisiana Department of Health & Hospitals
500 Laurel Street, Baton Rouge, LA 70801
225-342-6429* toll free 866-280-7737
The accrediting agency for our facilities is: The Joint Commission, (800)-994-6610"


In an interview 12/30/13 at 3:30 p.m., S1Regulatory Coordinator verified that the pamphlet provided to patients included an administrative number for each campus, but did not provide information concerning whom to contact for a complaint or grievance. The regulatory coordinator further reported that the numbers listed in the pamphlet were to administrative secretary phones on each campus. S1Regulatory Coordinator stated that the secretaries take the information and route it to the appropriate persons, for example Dietary, or Housekeeping. When asked if the phones are answered at all times, S1Regulatory Coordinator reported that at Campus B the phone is answered only during business hours Monday through Friday. She stated there was no answering service or device on those phones after hours or weekends. S1Regulatory Coordinator reported the Campus C phone is answered by an automated system, and voicemail was checked several times a day by the administrative secretary only during business hours, not after hours or on the weekend. S1Regulatory Coordinator reported that S2Grievance Coordinator is in the chain of steps (of grievance notification). She said S2Grievance Coordinator gets the grievances from the incident reporting line. She (S2Grievance Coordinator) receives them electronically and sends out a letter to the complainant. After review of the pamphlet provided to patients, S1Regulatory Coordinator verified that there was not information informing patients (and/or representatives) whom to contact to lodge a complaint or grievance. S1Regulatory Coordinator verified the address listed for the Louisiana Department of Health & Hospitals was incorrect.



17091

Based on record review and interview the hospital failed to have a clearly explained procedure for the submission of a patient's/patient representative's grievance to the hospital.
Findings:


Review of hospital policy titled, "Grievance Process" # A-110, revised date 10/10, and provided as current by S1Regulatory Coordinator, revealed the following, in part:
Purpose: To provide/maintain a timely, reasonable, and consistent grievance process in which prompt resolution to patient/patient representative grievances is achieved.
Policy:
1. Patients/patient representatives are informed via written Patient Rights and Responsibilities documents on how to contact BRGMC (Baton Rouge General Medical Center) Administrative Offices or the LA Department of Health and Hospitals to express concerns regarding care or service. Information on how to contact Joint Commission is published on the BRGMC website.
2. Grievances are investigated and resolved in collaboration with applicable interdisciplinary staff, hospital and medical staff leadership...
4. BRGMC will review, investigate, each grievance within a reasonable time frame...
5. A written response is sent to the patient/patient representative within 7-10 days from the time the Grievance Manager is notified. Should the grievance require extensive investigation, the patient/patient representative will receive a letter acknowledging receipt of the grievance and of the ongoing investigative review. A second letter will be issued containing all of the requirements as noted below...
Procedure:
1. Any staff member receiving complaint will attempt to resolve it immediately beginning with the patient care staff. If the situation cannot be immediately resolved, it is directed to the Grievance Manager, documented in the incident reporting system, and reviewed by the Grievance Committee.
2. Upon receipt of grievance, if it has not been entered into the incident reporting system, it is done at this time.
3. Grievance Manager reviews grievance and adds appropriate department managers and director to follow-up list.
4. Should the grievance require more extensive investigation, an initial letter will be sent to the patient/patient representative notifying him/her that grievance process is underway.
5. Grievance Manager works with all involved units and departments and/or the AOC to investigate by gathering and reviewing information from interviews and the medical records. Based on the investigative findings, the Grievance Manager ensures that appropriate actions are taken to resolve the patient ' s grievance.
6. The Grievance Manager ensures that each designated Manager/Director follows up with his/her portion of the investigation in a timely, reasonable, and consistent manner. Each week, an open file review is completed and any Manager/Director with outstanding items receives reminder notifications.
7. Once all designated Managers/Director s have satisfactorily addressed the grievance, the case is closed and the Grievance Manager prepares a letter informing the patient/patient representative of the grievance process and outcome of the investigation...


Review of a pamphlet, provided by the hospital to patients on admission, revealed it included Patient Rights and Responsibilities. Further review revealed, in part, the following under Patient's Rights:
"* Lodging a concern of relevance about care or service.
Mid City Administration: 387-7767
Bluebonnet Administration: 763-4040
*receiving a written response to your grievance within 7-10 days.
The licensing agency for our facility is:
Louisiana Department of Health & Hospitals
500 Laurel Street, Baton Rouge, LA 70801
225-342-6429* toll free 866-280-7737
The accrediting agency for our facilities is The Joint Commission, (800)-994-6610"


In an interview 12/30/13 at 3:30 p.m., S1Regulatory Coordinator reported that the phone numbers listed in the pamphlet provided to patients were Administration secretary numbers answered during regular business hours. S1Regulatory Coordinator reported they (the administrative secretaries) take the complaint/grievance information and route it to the appropriate department or transfer the call to an appropriate department, such as Food service, Housekeeping, etc. After hours there is a recording, but she was not sure what recording was on the phone. S1Regulatory Coordinator further reported that at campus B the phone number was answered during business hours Monday through Friday. She further reported there was no message service after hours or on weekends. S1Regulatory Coordinator verified that after business hours and on weekends the provided number at Campus B did not allow a patient or patient representative to phone in a complaint or grievance. S1Regulatory Coordinator reported the calls to the Administration number at Campus C were answered by automation and the voicemail was checked several times a day during business hours, but not after business hours or on weekends.

In an interview 12/30/13 at 4:05 p.m. S3Director Risk Management reported that Administrative Assistants would receive complaint/grievance information via the phone numbers (listed on the pamphlet given to patients) or the answering service. The administrative secretary did not enter the grievance information into the incident/complaint system, but instead would relay the information to the appropriate person. S3Director Risk Management reported that any employee with access to a computer terminal could enter information related to a complaint or grievance 24 hours a day, 7 days a week. He stated that the information was entered, but the employee entering did not have to identify themselves and the computer did not track who entered the information. S3Director Risk Management reported the system was set up so that the person entering the information could be anonymous, thereby making it more likely that an employee would be able to enter information about a problem more freely without the concern of reprisal. He added that there was also another system for employees to report actions and situations they themselves felt were wrong or unethical. When asked about the process for patient/patient representative complaints and grievances, S3Director Risk Management stated there were two (2) ways the Grievance department received complaints. One was that the patient/representative could call the listed numbers and leave a message that would be put into the system the next morning, or if the complaint was received by an operator, the call could be forwarded to S2Grievance Coordinator's cell phone. S3Director Risk Management verified that employees could enter a grievance into electronic system, but there was no way to ensure that all grievances were entered, and referred to the Grievance Manager as per the hospital policy.


After a review of grievances printed from the Incident Reporting System, S3Director Risk Management reported that the "Incident date" represented the date the incident was reported to have occurred. The "Discovered date" could either be the date the incident/grievance was reported to the hospital or, in some cases, could be the date the complainant discovered the occurrence. S3Director Risk Management explained that the "Entered date" was the date that the information was entered into the system. He verified the "Entered date" might not be the same date the grievance was received by someone at the hospital.




17091

Based on record review and interview the hospital failed to ensure the patient's representative filing a grievance was notified in writing of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 (#3) closed grievance investigations of a total of 4 (#3, #R1, #R2, #R3) grievance investigations reviewed.
Findings:


Review of hospital policy titled, "Grievance Process" # A-110, revised date 10/10, and provided as current by S1Regulatory Coordinator, revealed the following, in part:
Purpose: To provide/maintain a timely, reasonable, and consistent grievance process in which prompt resolution to patient/patient representative grievances is achieved.
Policy:
1. Patients/patient representatives are informed via written Patient Rights and Responsibilities documents on how to contact BRGMC (Baton Rouge General Medical Center) Administrative Offices or the LA Department of Health and Hospitals to express concerns regarding care or service. Information on how to contact Joint Commission is published on the BRGMC website...
5. A written response is sent to the patient/patient representative within 7-10 days from the time the Grievance Manager is notified. Should the grievance require extensive investigation, the patient/patient representative will receive a letter acknowledging receipt of the grievance and of the ongoing investigative review. A second letter will be issued containing all of the requirements as noted below...
Procedure:
1. Any staff member receiving complaint will attempt to resolve it immediately beginning with the patient care staff. If the situation cannot be immediately resolved, it is directed to the Grievance Manager, documented in the incident reporting system, and reviewed by the Grievance Committee...
4. Should the grievance require more extensive investigation, an initial letter will be sent to the patient/patient representative notifying him/her that grievance process is underway...
7. Once all designated Managers/Director s have satisfactorily addressed the grievance, the case is closed and the Grievance Manager prepares a letter informing the patient/patient representative of the grievance process and outcome of the investigation...


Patient #3
Review of the email documentation by S8Staff Attorney to S2Grievance Coordinator dated 10/28/13 at 1:15 p.m. revealed the mother of Patient #3 came in person to the office of S2Grievance Coordinator to voice her complaint regarding the nursing care her daughter received during a hospital stay from 09/25/13 to 10/07/13.
The mother's name, address and telephone number were included at the bottom of the email.

Review of the grievance investigation for Patient #3 revealed in part the following:
Incident date: 09/30/13
Discovered date: 11/07/13
Entered date: 11/08/13

Incident Description: Patient #3 - Patient's mother called stating Patient #3 came in for surgery for a colostomy reversal on 09/25/13 and was discharged on 10/07/13. She was in ICU until 9/30 and was moved to Unit "A". The complaint is she had the colostomy put in 3 years ago for a wound that would not heal and had the reversal because the wound had closed up and healed. When she was returned to Group Home "D" the wound had reopened. No one form BRGMC disclosed this information. She was supposed to be turned every 2 hours. She feels that the nursing staff did not do their job. Now since the wound has reopened, she is being given wound care at Group Home "D".

Incident Action Plan:
S2Grievance Coordinator - received date 11/08/13, complete, Last Update; 12/26/13. 11/08/13 File set up. I contacted patient's mother and apologized that I have been out of the office, explained that the investigation had been started. 11/11/13 Reviewed. Letter #1-11/18/13 Reviewed. Awaiting S15Unit Manager 11/25/13 Reviewed. Assessment completed. Letter #2 Case Closed.
S3Director Risk Management - Reviewed. Last update 12/20/13.
S15Unit Manager - Date received: 11/08/13, Complete: 11/21/13. In regards to the sacral wound opening, I cannot find any clear documentation that this occurred. We do have documentation that the patient had a healing stage III/IV to coccyx as documented by ET (Enterostomal) nurse. From documentation, I can see that the patient was placed in her wheelchair per MD (physician) request and chair several times throughout stay. It is documented that the patient was repositioned and turned but was not 100% documented and there are occasions that the patient/sitter refused. Skin assessment was completed every shift. We were not 100% compliant in documentation of turning every 2 hours, so I will reeducate staff in the upcoming meeting and ongoing.

Attached to the grievance documentation was a copy of a letter dated 11/25/13 and addressed to Patient #3 at the address of Group Home "D" (Different from the address of the patient's mother). There was no documented evidence that the patient's mother was informed of the resolution of her complaint. There was no documented evidence of the first letter sent according to the notes of S2Grievance Coordinator on 11/18/13.

In an interview with the mother of Patient #3 on 12/26/13 at 930 a.m., she stated had not received anything in writing from the hospital regarding the complaint she had filed regarding her daughter's care during her hospital stay from 09/25/13 to 10/07/13.

In a face-to-face interview on 12/30/13 at 3:45 p.m. S3Director Risk Management verified the grievance regarding Patient #3 was not promptly resolved. S3Director Risk Management verified the written notice of the investigation was sent to the patient and not the patient's representative who had voiced the complaint.

Based on record review, and staff interview, the RN (Registered Nurse) failed to effectively supervise and evaluate the nursing care of each patient. This was evidenced by:
1) Failing to ensure the patient's physician was notified of the development of a pressure ulcer;
2) Failing to ensure wound care was performed in accordance with physician's orders;
3) Failing to assess the patient's pressure ulcer, and;
4) Failing to coordinate follow up care of the patient's pressure ulcer with discharge planning staff for 1 (#3) of 2 (#3, #6) sampled patients reviewed with pressure ulcers out of a total sample of 10. Findings:

Review of the hospital policy titled, "Assessment/Reassessment" Number PE-110, revised date of 06/12 and provided as current by S1Regulatory Coordinator, revealed in part the following: Reassessment will be based on patient's diagnosis (change in diagnosis/problems), the care setting (transfer), patient's desire for care and response to care, and his/her consent to treatment. Reassessment (physical exam) by the RN will occur a minimum of once every 24 hours and at the time of discharge. Physician notification will occur as warranted by reassessment findings....

Review of the hospital policy titled, "Wound Care Guidelines" Number PE-165, revised date of 05/12 and provided as current by S1Regulatory Coordinator, revealed the Braden Scale would be used to identify adult patients at risk for development of pressure ulcers. The policy revealed a Pressure Ulcer Prevention Protocol would be implemented for patients with a total score of 18 or less. The policy revealed reassessment would be done daily. The policy also revealed the physician would be notified of any change in skin integrity or increased wound size.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 30 year old female admitted to the hospital on 09/25/13 for surgical reversal of a diverting colostomy. The record revealed the patient's medical history included Diabetes Mellitus, Hydrocephalus, and Paraplegia. The History and Physical also revealed the patient had a recent history of a Sacral Decubitus Ulcer and a diverting colostomy was done approximately one year prior to the current admission. The record revealed the Sacral Decubitus Ulcer was healed and the patient and her family were requesting colostomy reversal. The record also revealed the patient was wheel chair bound and resided in a group home.

Review of the record revealed the patient's surgical reversal of the colostomy was performed on 09/25/13 and the patient was admitted to the intensive care unit from 09/25/13 to 09/30/13. On 09/30/13 at 5:36 p.m. the patient was admitted to Unit "A" (Medical/Surgical unit). Review of the record revealed the "Pressure Ulcer Prevention Protocol" was initiated for Patient #3 on 09/29/13 at 10:00 p.m. for a Stage 1 ulcer (reddened, unbroken skin) on both feet.

Review of the nursing documentation revealed on 09/30/13 at 7:50 p.m. S17RN documented the ET (Enterostomal Therapy) was initiated and the care plan modified, but there was no documentation of why ET was initiated. There was no documented evidence of a sacral/coccyx wound on 09/30/13.

Review of the nursing documentation dated 10/01/13 at 7:50 a.m., revealed S20RN documented "yes" to skin breakdown, but did not document where the skin breakdown was or the appearance of the breakdown.

Review of the ET documentation by S9ET Nurse on 10/01/13 at 12:00 p.m. revealed a pressure ulcer was identified on the patient's coccyx measuring 2.5 cm (centimeters) in length, 1.5 cm wide, and 1.4 cm deep. The assessment documented by S9ET Nurse revealed she was unable to Stage the wound and applied a hydrogel dressing to the wound. There was no documented evidence that S9ET Nurse notified the patient's physician of the development of a pressure ulcer.

Review of the physician's orders revealed an entry documented by S9ET Nurse on 10/01/13 (no time on order) as follows: 1) Coccyx ulcer (resolving Stage iii-iv) - Cleanse with Normal Saline, Pat dry. Apply Intrasite gel, cover with 4 X 4 gauze, secure with foam tape. Change dressing once daily and as needed soiled. 2) Bilateral groin - apply EPC (Extra Protection Cream) topically every 6 hours and as needed soiled. 3) Continue pressure ulcer prevention protocol.

Further review of the electronic nursing documentation with S13Manager of Clinical Informatics revealed no documented evidence that the nursing staff notified the patient's physician of the development of a pressure ulcer. Review of the nursing documentation revealed no documented evidence that the wound care to the coccyx ulcer was done on 10/02/13, 10/03/13, 10/04/13, 10/06/13, and 10/07/13 (Day of discharge to group home). Review of the nursing documentation on 10/05/13 at 5:10 a.m., revealed the sacral/coccyx pressure ulcer dressing was changed by S21RN. There was no documented evidence of an assessment of the pressure ulcer. S13Manager of Clinical Informatics verified the above findings after reviewing all possible areas of documentation of wound assessments and wound care in the electronic record. S13Manager of Clinical Informatics verified there was no documented evidence of any wound assessments after 10/01/13 when S9ET Nurse identified the pressure ulcer.

Further review of the nursing documentation and the "Supportive Palliative Care" notes documented by the Care Managers (Discharge Planning) revealed no documented evidence the Care Managers were notified of the patient's pressure ulcer or need for wound care upon discharge.

Review of the physician's discharge orders dated 10/07/13 at 3:50 p.m. revealed the following: "D/C (discharge) home. Resume meds. Follow up 2 weeks." There was no documented evidence of any discharge orders for the patient's wound care.

In a face-to-face interview on 12/27/13 at 10:00 a.m., S5RN verified she was assigned to Patient #3 on 10/07/13 when the patient was discharged. When asked if she did an assessment of the patient, she stated she did not remember if the patient had a wound. S5RN stated she did remember calling report to the receiving facility, but did not remember what she reported or to whom she spoke with at the receiving facility. After reviewing the electronic record with S1Regulatory Coordinator and S22CNO (Chief Nursing Officer), S5RN verified she did not document any wound care or wound assessment of Patient #3's pressure ulcer. S5RN verified the patient was discharged at 5:40 p.m. S1Regulatory Coordinator verified the only dressing change documented by the nursing staff was on 10/05/13 and that dressing change did not include an assessment of the pressure ulcer. S5RN stated the patient's medical record is copied and sent to the receiving facility by the care managers. S1Regulatory Coordinator verified there was no documentation that a report was given to the receiving facility.

In a face-to-face interview on 12/27/13 at 11:00 a.m., S6Care Management verified she handled Patient #3's discharge on 10/07/13. S6Care Management stated she faxed the physician's discharge order dated 10/07/13, the labs, x-rays, and medication reconciliation record to the receiving facility. S6Care Management stated the nurse would have communicated the wound care in her report. S6Care Management stated she did not remember this patient. S6Care Management stated she did not know the patient had a wound. S7Director of Care Management was also present for the interview and stated if they had seen an order for the wound care they would have made sure the receiving facility had the supplies and were informed of the wound care. S7Director of Care Management verified there was no order to continue wound care and verified the Care Management staff did not know the patient had a wound.

In a face-to-face interview on 12/27/13 at 11:20 a.m. S9ET Nurse verified she had assessed Patient #3 on 10/01/13 and found an open wound in the coccyx area. S9ET Nurse stated she was unable to stage the wound because the patient had scar tissue in the area and she did not know what the ulcer was in the past. S9ET Nurse verified the assessment on 10/01/13 was the only time she or any other ET Nurse had seen the patient. After reviewing her entry in the physician orders dated 10/01/13, S9ET Nurse stated she wrote the orders, but did not receive the orders as a verbal order from S14Surgeon. S9ET Nurse verified she did not notify the patient's physician of the pressure ulcer that was identified on 10/01/13.

In a face-to-face interview on 12/27/13 at 3:45 p.m., S14Surgeon stated he was very familiar with Patient #3 and stated the patient had a Stage 3 or 4 pressure ulcer about a year ago and he did a diverting colostomy to heal the pressure ulcer. S14Surgeon stated the patient was paralyzed, incontinent, and wheel chair bound. S14Surgeon stated recently the patient returned to have the colostomy reversed. S14Surgeon stated he did the surgery and patient did fine but had a post-operative ileus. S14Surgeon stated he was not aware that the patient had developed another pressure ulcer until the patient's mother contacted him after the patient was discharged. S14Surgeon stated the ET nurses have his cell phone number and could have called him. S14Surgeon stated if he had known of the pressure sore he would have started treatment.

In a face-to-face interview on 12/30/13 at 9:50 a.m., S15Unit Manager for Unit "A" verified Patient #3 was on Unit "A" and stated she did remember the patient. S15Unit Manager stated she knew the patient's history of having a sacral wound and that was the reason she had a diverting colostomy. S15Unit Manager verified she had reviewed the patient's record and found the every 2 hour turning had not been completed. S15Unit Manager stated she had reviewed the patient's record on 11/21/13 and had missed the wound care orders. S15Unit Manager stated she did not know the patient had developed a wound until she reviewed the record again last Friday (12/27/13). S15Unit Manager verified she found the wound care orders and found that the wound care was not done as ordered. S15Unit Manager also verified the only dressing change was done on 10/05/13 and there was no documentation of a wound assessment at that time. S15Unit Manager verified the only assessment of the pressure ulcer documented in the record was done by the ET nurse on 10/01/13. S15Unit Manager stated she was not aware that the physician was not notified of the patient's pressure ulcer until this survey.

In a face-to-face interview on 12/27/13 at 10:20 a.m., S17RN stated she did not remember Patient #3. After reviewing the patient's record with S1Regulatory Coordinator, she verified she had entered the trigger for the ET nurse to see the patient. S17RN verified she did not document why she entered a trigger for the ET nurse. S17RN stated she did remember the patient had a sitter and the sitter called her in when she changed the patient. S17RN stated she observed the sacral area but does not remember the appearance. S17RN was unable to explain why she triggered the ET nurse to see the patient.

Review of the nursing assessment and Interdisciplinary Progress Notes from Group Home "D" (Receiving facility for Patient #3) revealed in part the following:
Nursing Assessment - 10/07/13 at 6:45 p.m. ....Dark brown foam dressing to sacrum, dated 10/05/13. Approximately 4 cm opening to sacrum under dressing...
Interdisciplinary Progress Notes documented by the physician: 10/08/13 at 11:00 a.m. - Sacral wound - Coccyx wound 3 cm X 1.2 cm X 1 cm.... A: Coccyx Stage III....P:...Clean sacral wound twice a day with wound cleanser, opticell AG and cover with border....

Based on record review and staff interviews the Registered Nurse failed to keep current the nursing care plan as evidenced by failure to follow the plan of care related to turning the patient every 2 hours as directed in the Pressure Ulcer Prevention Protocol and failure to perform wound care as ordered for 1 (#3) of 2 (#3, #6) sampled patients with pressure ulcers out of a total sample of 10. Findings:

Review of the hospital policy titled, "Wound Care Guidelines" Number PE-165, revised date of 05/12 and provided as current by S1Regulatory Coordinator, revealed the Braden Scale would be used to identify adult patients at risk for development of pressure ulcers. The policy revealed a Pressure Ulcer Prevention Protocol would be implemented for patients with a total score of 18 or less. The policy revealed reassessment would be done daily. The policy also revealed the physician would be notified of any change in skin integrity or increased wound size.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 30 year old female admitted to the hospital on 09/25/13 for surgical reversal of a diverting colostomy. The record revealed the patient's medical history included Diabetes Mellitus, Hydrocephalus, and Paraplegia. The History and Physical also revealed the patient had a recent history of a Sacral Decubitus Ulcer and a diverting colostomy was done approximately one year prior to the current admission. The record revealed the Sacral Decubitus Ulcer was healed and the patient and her family were requesting colostomy reversal. The record also revealed the patient was wheel chair bound and resided in a group home.

Review of the record revealed the patient's surgical reversal of the colostomy was performed on 09/25/13 and the patient was admitted to the intensive care unit from 09/25/13 to 09/30/13. On 09/30/13 at 5:36 p.m. the patient was admitted to Unit "A" (Medical/Surgical unit). Review of the record revealed the "Pressure Ulcer Prevention Protocol" was initiated for Patient #3 on 09/29/13 at 10:00 p.m. for a Stage 1 ulcer (reddened, unbroken skin) on both feet.

Review of the Plan of Care for Patient #3 revealed pressure ulcer prevention was initiated on 09/28/13 at 8:39 a.m. Review of the Pressure Ulcer Prevention Protocol dated 09/29/13 revealed the following interventions were to be implemented for Patient #3: 1. Turn patient every 2 hours and position at 30 degrees angle unless contraindicated. Use foam wedge if necessary. 2. Place hospital bed in "prevention mode" if not on specialty bed. 3. Float heels off bed surface with pillow. 4. Place pillow in chair when patient is sitting in bedside chair. 5. Cleanse and moisturize skin with Aloe Vesta 3:1 Foam Cleanser and apply Aloe Vesta Protective Ointment to all areas of intact skin. Further review of the Pressure Ulcer Prevention Protocol for Patient #3 revealed the protocol was indicated due to a Braden Score of 18 or below, paralysis, and immobility. The protocol also revealed the patient had a Stage I pressure ulcer present (reddened, unbroken skin) and included the following interventions: 1. Cleanse with perineal cleanser - Aloe Vesta 3:1 Foam Cleanser. 2. Apply Aloe Vesta Protective Ointment twice daily, after bath and at bedtime, and as needed. 3. Notify physician of change in skin integrity. Further review of the Plan of Care revealed the care plan was revised on 10/01/13 at 12:00 p.m. by S9ET Nurse to include a pressure ulcer. Interventions included topical meds, monitor nutrition, position change, wound care, turn every 2 hours, and pressure ulcer prevention. The goals identified were signs/symptoms of wound healing within 2 - 4 weeks, no breakdown, maintain skin integrity, and adequate nutrition.

On 12/27/13 at 2:20 p.m. the patient's electronic record was reviewed with S13Manager of Clinical Informatics. Review of the nursing documentation of turning and repositioning Patient #3 revealed no documented evidence that the patient was turned every 2 hours during the following time periods:
09/30/13 at 7:32 p.m. to 10/01/13 at 5:38 a.m. (10 hours)
10/01/13 at 5:38 a.m. to 2:00 p.m. (8.5 hours)
10/01/13 at 11:31 p.m. to 10/02/13 at 5:30 a.m. (6 hours)
10/02/13 at 1:00 p.m. to 10/03/13 at 12:38 a.m. (11.5 hours)
10/03/13 at 7:30 p.m. to 10/04/13 at 12:50 a.m. (5 hours)
10/04/13 at 12:50 a.m. to 1:21 p.m. (12 hours)
Further review of the turning and repositioning documentation revealed the patient remained in bed from 10/04/13 at 2:48 p.m. to 10/07/13 at 5:40 p.m. when the patient was discharged. There was no documented evidence that the patient was turned and repositioned during the last 3 days of the patient's hospital stay. S13Manager of Clinical Informatics verified the above dates and times and verified there was no documented evidence the patient was turned every 2 hours during these hours.
Review of the nursing documentation revealed no documented evidence that the wound care to the coccyx ulcer was done on 10/02/13, 10/03/13, 10/04/13, 10/06/13, and 10/07/13 (Day of discharge to group home). S13Manager of Clinical Informatics verified the above findings after reviewing all possible areas of documentation of wound care in the electronic record.

Review of the ET documentation by S9ET Nurse on 10/01/13 at 12:00 p.m. revealed a pressure ulcer was identified on the patient's coccyx measuring 2.5 cm (centimeters) in length, 1.5 cm wide, and 1.4 cm deep. The assessment documented by S9ET Nurse revealed she was unable to Stage the wound and applied a hydrogel dressing to the wound.

Review of the physician's orders revealed an entry documented by S9ET Nurse on 10/01/13 (no time on order) as follows: 1) Coccyx ulcer (resolving Stage iii-iv) - Cleanse with Normal Saline, Pat dry. Apply Intrasite gel, cover with 4 X 4 gauze, secure with foam tape. Change dressing once daily and as needed soiled. 2) Bilateral groin - apply EPC (Extra Protection Cream) topically every 6 hours and as needed soiled. 3) Continue pressure ulcer prevention protocol.

In a face-to-face interview on 12/27/13 at 10:00 a.m., S5RN verified she was assigned to Patient #3 on 10/07/13 when the patient was discharged. After reviewing the electronic record with S1Regulatory Coordinator and S22CNO (Chief Nursing Officer), S5RN verified she did not document any wound care or wound assessment of Patient #3's pressure ulcer. S5RN verified the patient was discharged at 5:40 p.m. S1Regulatory Coordinator verified the only dressing change documented by the nursing staff was on 10/05/13.

In a face-to-face interview on 12/30/13 at 9:50 a.m., S15Unit Manager for Unit "A" verified Patient #3 was on Unit "A" and stated she did remember the patient. S15Unit Manager stated she knew the patient's history of having a sacral wound and that was the reason she had a diverting colostomy. S15Unit Manager verified she had reviewed the patient's record and found the every 2 hour turning had not been completed. S15Unit Manager stated she had reviewed the patient's record on 11/21/13 and had missed the wound care orders. S15Unit Manager stated she did not know the patient had developed a wound until she reviewed the record again last Friday (12/27/13). S15Unit Manager verified she found the wound care orders and found that the wound care was not done as ordered. S15Unit Manager also verified the only dressing change was done on 10/05/13 and there was no documentation of any other wound care.

Based on record review and interviews, the hospital failed to reassess a patient's discharge plan for factors that may affect the continuing care needs of the patient as evidenced by failing to inform the post-hospital facility of the presence of a pressure ulcer and the necessary treatment for the pressure ulcer for 1 of 1 (#3) sampled discharged patients with pressure ulcers out of a total sample of 10. Findings:

Review of the hospital policy titled, "Discharge Planning", number CC-110, effective date 10/97, last revised date 9/12, presented as current policy by S1Regulatory Coordinator revealed in part the following:
Purpose: To identify patients admitted to the hospital that are in need of discharge planning, to provide these identified patients with a discharge plan of care and to communicate appropriately to the patients and to agencies that will be providing follow up care.
Policy: Preparations for discharge are a continuous, interdisciplinary process that begins on admission and is inclusive of all identified needs related to the hospitalization. The Discharge plan will be reviewed and updated on an ongoing basis and based on the patients' continuing needs. Re-assessment of the discharge plan will be done at least every 7 days....All members of the interdisciplinary team participating in the care of the patient are responsible for: Collaborating with the nursing staff and other members of the interdisciplinary team regarding the discharge plan of care. Documenting encounters in the patient's medical record, as well as appropriate information on the Discharge Plan section of the Plan of Care and/or Discharge assessment....

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 30 year old female admitted to the hospital on 09/25/13 for surgical reversal of a diverting colostomy. The record revealed the patient's medical history included Diabetes Mellitus, Hydrocephalus, and Paraplegia. The History and Physical also revealed the patient had a recent history of a Sacral Decubitus Ulcer and a diverting colostomy was done approximately one year prior to the current admission. The record revealed the Sacral Decubitus Ulcer was healed and the patient and her family were requesting colostomy reversal. The record also revealed the patient was wheel chair bound and resided in a group home.

Review of the record revealed the patient's surgical reversal of the colostomy was performed on 09/25/13 and on 09/30/13 at 5:36 p.m. the patient was admitted to Unit "A" (Medical/Surgical unit).

Review of the ET documentation by S9ET Nurse on 10/01/13 at 12:00 p.m. revealed a pressure ulcer was identified on the patient's coccyx measuring 2.5 cm (centimeters) in length, 1.5 cm wide, and 1.4 cm deep. The assessment documented by S9ET Nurse revealed she was unable to Stage the wound and applied a hydrogel dressing to the wound.

Review of the physician's orders revealed an entry documented by S9ET Nurse on 10/01/13 (no time on order) as follows: 1) Coccyx ulcer (resolving Stage iii-iv) - Cleanse with Normal Saline, Pat dry. Apply Intrasite gel, cover with 4 X 4 gauze, secure with foam tape. Change dressing once daily and as needed soiled. 2) Bilateral groin - apply EPC (Extra Protection Cream) topically every 6 hours and as needed soiled. 3) Continue pressure ulcer prevention protocol.

Review of the electronic nursing documentation with S13Manager of Clinical Informatics on 12/27/13 at 2:20 p.m. revealed no documented evidence that the nursing staff notified the patient's physician of the development of a pressure ulcer. Review of the nursing documentation revealed no documented evidence the Care Managers were notified of the patient's pressure ulcer or need for wound care upon discharge. S13Manager of Clinical Informatics confirmed the above findings during the review of the electronic record.

Review of the physician's discharge orders dated 10/07/13 at 3:50 p.m. revealed the following: "D/C (discharge) home. Resume meds. Follow up 2 weeks." There was no documented evidence of any discharge orders for the patient's wound care.

Review of the initial Discharge Planning documented by S23RN on 09/25/13 at 8:26 a.m. revealed the patient's living situation prior to admission was a nursing home, the patient had mobility concerns, and needed help at home. Review of the Supportive Palliative Care (Care Management Notes) revealed the social worker documented on 09/26/13 at 2:43 p.m. that the patient's living situation was a group home and the patient's prior functioning status was 24 hour supervision and assistance. The note also revealed the patient resided in Group Home "D" and was paralyzed below the waist and was non-ambulatory. The note dated 09/26/13 revealed sitters would be provided by Group Home "D". There was no other documentation by the social worker until 10/07/13, which revealed the following: "Patient discharged back to group home. Contacted home and faxed orders, labs, med rec (medication reconciliation) and x-rays." There was no documented evidence the social worker was informed of the patient's pressure ulcer or the continuing treatment of the pressure ulcer.

Review of the hospital's Incident Reporting System documentation (Complaint/Grievance)dated 11/07/13 revealed the mother of Patient #3 complained that when Patient #3 returned to Group Home "D" her wound had reopened and no one from [hospital] disclosed that the patient had a sacral/coccyx wound. Review of the email documentation of the mother's complaint, documented by S8Staff Attorney, revealed the patient's mother came to the office of S8Staff Attorney on 10/28/13. The email revealed the following: "....She (Patient #3) was discharged back to Group Home "D" on October 7th, using her own wheelchair and transported by a transport van owned by Group Home "D". Once back at Group Home "D" a full assessment was performed by their in-house medical staff. It was found that the wound (Sacral/Coccyx Pressure Ulcer) had reopened. A nurse named _____ with Group Home "D" called the [hospital] charge nurse on October 8th to complain that the wound had reopened and no one from [hospital] had notified them of that, nor did the discharge paperwork address the issue...."

In a face-to-face interview on 12/27/13 at 10:00 a.m., S5RN verified she was assigned to Patient #3 on 10/07/13 when the patient was discharged. When asked if she did an assessment of the patient, she stated she did not remember if the patient had a wound. S5RN stated she did remember calling report to the receiving facility, but did not remember what she reported or to whom she spoke at the receiving facilty. S5RN stated she did not remember reporting to the facility about the patient's pressure ulcer. After reviewing the electronic record with S1Regulatory Coordinator and S22CNO (Chief Nursing Officer), S5RN verified she did not document any wound care or wound assessment of Patient #3's pressure ulcer. S5RN verified the patient was discharged at 5:40 p.m. on 10/07/13. S5RN stated the patient's medical record is copied and sent to the receiving facility by the care managers. S1Regulatory Coordinator verified there was no documentation that a report was given to the receiving facility.

In a face-to-face interview on 12/27/13 at 11:00 a.m., S6Care Management verified she handled Patient #3's discharge on 10/07/13. S6Care Management stated she faxed the physician's discharge order dated 10/07/13 (Order only for "D/C home, resume meds, follow up 2 weeks"), the labs, x-rays, and medication reconciliation record to the receiving facility. S6Care Management stated the nurse would have communicated the wound care in her report. S6Care Management stated she did not remember this patient. S6Care Management stated she did not know the patient had a wound. S7Director of Care Management was also present for the interview and stated if they had seen an order for the wound care they would have made sure the receiving facility had the supplies and were informed of the wound care. S7Director of Care Management verified there was no order to continue wound care and verified the Care Management staff did not know the patient had a wound.

In a face-to-face interview on 12/27/13 at 3:45 p.m., S14Surgeon stated he was very familiar with Patient #3 and stated the patient had a Stage 3 or 4 pressure ulcer about a year ago and he did a diverting colostomy to heal the pressure ulcer. S14Surgeon stated the patient was paralyzed, incontinent, and wheel chair bound. S14Surgeon stated recently the patient returned to have the colostomy reversed. S14Surgeon stated he did the surgery and patient did fine but had a post-operative ileus. S14Surgeon stated he was not aware that the patient had developed another pressure ulcer until the patient's mother contacted him after the patient was discharged. S14Surgeon stated the ET nurses have his cell phone number and could have called him. S14Surgeon stated if he had known of the pressure sore he would have started treatment.

Based on record review and interviews, the hospital failed to ensure necessary medical information for follow up care was communicated with the receiving facility as evidenced by failing to inform the post-hospital facility of the patient's pressure ulcer and provide instructions for the care of the wound for 1 of 1 (#3) sampled discharged patients with a pressure ulcer out of a total sample of 10. Findings:

Review of the hospital policy titled, "Admission/Discharge/Transfer" number CC-100, revised date of 10/12, presented as current policy by S1Regulatory Coordinator, revealed in part the following: ....Transfers to Another Healthcare Facility: ....A copy of pertinent medical records will be sent to the receiving facility/unit for transferred patients, which include physical exam, discharge medications, diet, treatments, and any other follow-up instructions....Report will be called to the receiving facility. Patient transfer disposition shall be accurately documented in the computer via discharge function.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 30 year old female admitted to the hospital on 09/25/13 for surgical reversal of a diverting colostomy. The record revealed the patient's medical history included Diabetes Mellitus, Hydrocephalus, and Paraplegia. The History and Physical also revealed the patient had a recent history of a Sacral Decubitus Ulcer and a diverting colostomy was done approximately one year prior to the current admission. The record revealed the Sacral Decubitus Ulcer was healed and the patient and her family were requesting colostomy reversal. The record also revealed the patient was wheel chair bound and resided in a group home.

Review of the record revealed the patient's surgical reversal of the colostomy was performed on 09/25/13 and the patient was admitted to the intensive care unit from 09/25/13 to 09/30/13. On 09/30/13 at 5:36 p.m. the patient was admitted to Unit "A" (Medical/Surgical unit).

Review of the ET documentation by S9ET Nurse on 10/01/13 at 12:00 p.m. revealed a pressure ulcer was identified on the patient's coccyx measuring 2.5 cm (centimeters) in length, 1.5 cm wide, and 1.4 cm deep. The assessment documented by S9ET Nurse revealed she was unable to Stage the wound and applied a hydrogel dressing to the wound.

Review of the physician's orders revealed an entry documented by S9ET Nurse on 10/01/13 (no time on order) as follows: 1) Coccyx ulcer (resolving Stage iii-iv) - Cleanse with Normal Saline, Pat dry. Apply Intrasite gel, cover with 4 X 4 gauze, secure with foam tape. Change dressing once daily and as needed soiled. 2) Bilateral groin - apply EPC (Extra Protection Cream) topically every 6 hours and as needed soiled. 3) Continue pressure ulcer prevention protocol.

Further review of the nursing documentation and the "Supportive Palliative Care" notes documented by the Care Managers (Discharge Planning) revealed no documented evidence the Care Managers were notified of the patient's pressure ulcer or need for wound care upon discharge. Review of the Care Manager notes revealed Patient #3 was discharged to Group Home "D" on 10/07/13. The Care Manager notes revealed Group Home "D" was contacted and orders, labs, medication reconciliation, and x-ray reports were faxed to the group home.

Review of the physician's discharge orders dated 10/07/13 at 3:50 p.m. revealed the following: "D/C (discharge) home. Resume meds. Follow up 2 weeks." There was no documented evidence of any discharge orders for the patient's wound care.

Review of the hospital's Incident Reporting System documentation (Complaint/Grievance)dated 11/07/13 revealed the mother of Patient #3 complained that when Patient #3 returned to Group Home "D" her wound had reopened and no one from [hospital] disclosed that the patient had a sacral/coccyx wound. Review of the email documentation of the mother's complaint, documented by S8Staff Attorney, revealed the patient's mother came to the office of S8Staff Attorney on 10/28/13. The email revealed the following: "....She (Patient #3) was discharged back to Group Home "D" on October 7th, using her own wheelchair and transported by a transport van owned by Group Home "D". Once back at Group Home "D" a full assessment was performed by their in-house medical staff. It was found that the wound (Sacral/Coccyx Pressure Ulcer) had reopened. A nurse named _____ with Group Home "D" called the [hospital] charge nurse on October 8th to complain that the wound had reopened and no one from [hospital] had notified them of that, nor did the discharge paperwork address the issue...."

In a face-to-face interview on 12/27/13 at 10:00 a.m., S5RN verified she was assigned to Patient #3 on 10/07/13 when the patient was discharged. When asked if she did an assessment of the patient, she stated she did not remember if the patient had a wound. S5RN stated she did remember calling report to the receiving facility, but did not remember what she reported or to whom she spoke at the receiving facilty. S5RN stated she did not remember reporting to the facility about the patient's pressure ulcer. After reviewing the electronic record with S1Regulatory Coordinator and S22CNO (Chief Nursing Officer), S5RN verified she did not document any wound care or wound assessment of Patient #3's pressure ulcer. S5RN verified the patient was discharged at 5:40 p.m. on 10/07/13. S5RN stated the patient's medical record is copied and sent to the receiving facility by the care managers. S1Regulatory Coordinator verified there was no documentation that a report was given to the receiving facility.

In a face-to-face interview on 12/27/13 at 11:00 a.m., S6Care Management verified she handled Patient #3's discharge on 10/07/13. S6Care Management stated she faxed the physician's discharge order dated 10/07/13 (Order only for "D/C home, resume meds, follow up 2 weeks"), the labs, x-rays, and medication reconciliation record to the receiving facility. S6Care Management stated the nurse would have communicated the wound care in her report. S6Care Management stated she did not remember this patient. S6Care Management stated she did not know the patient had a wound. S7Director of Care Management was also present for the interview and stated if they had seen an order for the wound care they would have made sure the receiving facility had the supplies and were informed of the wound care. S7Director of Care Management verified there was no order to continue wound care and verified the Care Management staff did not know the patient had a wound.