HospitalInspections.org

Based on policy review, medical record review and staff interview the facility failed to ensure that it had protected and promoted the rights of one (1) of one (1) patient, Patient #1.

Findings:

Cross Refer to:

A-0041 for failure to inform each patient whom to contact to file a grievance.

A-0042 For failure to provide a timely review and response of a grievance.

A-0046 for failure to provide the patient with a written response of its grievance resolution process.

A0048 For failure to include the patient/family in the development, implementation and revision of his/her plan of care.

A0049 For failure to provide the patient/family information, explanations, consequences, and options needed in order to make informed decisions regarding his/her care.

A0051 For failure to include the patient/family in care planning and treatment.

A0052 For failure to ensure that the patient/family was able to request or refuse treatment.

A0058 For failure to ensure that (1) one of (1) one patient was free from neglect.

Based on policy review and staff interview the facility failed to inform each patient whom to contact to file a grievance.

Findings:
Policy review " Patient Rights and Responsibilities " revealed " ...Complaints regarding your rights should be referred to Administration. In the absence of an Administration staff, the Administrator On Call should be notified ...You may also address your concerns or grievances to the Mississippi Department of Health at 601-354-7300. "

During an interview with the Director of Nursing on 07/28/10 he stated that the facility was unaware they were providing the incorrect number to its patients.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

Based on policy review and complaint documentation the facility failed to provide a timely review and response of a grievance.

Findings:
Policy review " Patient Grievances " revealed " ...The Patient Representative will analyze each complaint and appropriate staff will be involved within seven (7) working days from the time the complaint is filed and respond to the person complaining within those seven (7) working days ...Patient, family, parent or guardian will receive a written response from the appropriate Manger or Administrative Designee, which address the complaint within ten (10) working days. "

Facility documentation revealed that the written complaint from the family of patient #1 was received on June 27, 2010. The facility made phone calls to the complainant on 06/28/10 and 07/13/10. There was no documentation that a written response had been made.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

Based on policy review and staff interview the facility failed to provide the patient with a written response of its grievance resolution process.

Findings:
Policy review " Patient Grievances " revealed " ...The Patient Representative will analyze each complaint and appropriate staff will be involved within seven (7) working days from the time the complaint is filed and respond to the person complaining within those seven (7) working days ...Patient, family, parent or guardian will receive a written response from the appropriate Manger or Administrative Designee, which address the complaint within ten (10) working days. "

Facility documentation revealed that the written complaint from the family of patient #1 was received on June 27, 2010. The facility made phone calls to the complainant on 06/28/10 and 07/13/10. A written response dated 07/02/10 did not address the grievance resolution process.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

Based on policy review, clinical record review and staff interview the facility failed to include the patient/family in the development, implementation and revision of his/her plan of care for one (1) of one (1) patient, Patient #1.

Findings:

Policy review " Patient Rights and Responsibilities " revealed " Your rights and responsibilities will include, but are not limited to: ...Involvement in all aspects of your care. This includes the right to be informed of the diagnosis; prognosis; appropriate treatment options and their risks, benefits, alternatives, consequences of no treatment, and the results of care including any unanticipated adverse outcomes. "

On 06/09/10 Cardiologist #1 wrote orders for patient to be transferred to hospital #2 that owns/manages the current hospital (#1). There is no documentation that the plan for transfer was discussed with the patient/family prior to the orders being written. The patient/family refused transfer. They requested transfer to hospital #3 where her oncologist and their family support were located. The attending hospitalist refused to transfer the patient to the patient/family requested hospital #3.

In an interview with the Registered Nurse (RN) Patient Care Coordinator (PCC), she stated that the hospitalist stated that he had already made arrangements to get the patient transferred to hospital #2 and if they wanted to go to hospital #3 they would have to find their own doctor. The family did contact Cardiologist #2 who was a courtesy staff member at hospital #1.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

Based on policy review, clinical record review and staff interview the facility failed to provide the patient/family information, explanations, consequences, and options needed in order to make informed decisions regarding his/her care for one (1) of one (1) patient, Patient #1.

Findings:

Policy review " Patient Rights and Responsibilities " revealed " Your rights and responsibilities will include, but are not limited to: ...Involvement in all aspects of your care. This includes the right to be informed of the diagnosis; prognosis; appropriate treatment options and their risks, benefits, alternatives, consequences of no treatment, and the results of care including any unanticipated adverse outcomes. "

On 06/09/10 Cardiologist #1 wrote orders for patient to be transferred to hospital #2 that owns/manages the current hospital (#1). There is no documentation that the plan for transfer or other treatment options was discussed with the patient/family prior to the orders being written.

In an interview with the Registered Nurse (RN) Patient Care Coordinator (PCC), she stated that the hospitalist stated that he had already made arrangements to get the patient transferred to hospital #2 and if they wanted to go to hospital #3 they would have to find their own doctor.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.


Based on policy review, clinical record review and staff interview the facility failed to include the patient/family in care planning and treatment for one (1) of one (1) patient, Patient #1.

Findings:

Policy review " Patient Rights and Responsibilities " revealed " Your rights and responsibilities will include, but are not limited to: ...Involvement in all aspects of your care. This includes the right to be informed of the diagnosis; prognosis; appropriate treatment options and their risks, benefits, alternatives, consequences of no treatment, and the results of care including any unanticipated adverse outcomes. "

On 06/09/10 Cardiologist #1 wrote orders for patient to be transferred to hospital #2 that owns/manages the current hospital (#1). There is no documentation that the patient/family was involved in the care planning and treatment process. The patient/family refused transfer. They requested transfer to hospital #3 where her oncologist and their family support were located. The attending hospitalist refused to transfer the patient to the patient/family requested hospital #3.

In an interview with the Registered Nurse (RN) Patient Care Coordinator (PCC), she stated that the hospitalist stated that he had already made arrangements to get the patient transferred to hospital #2 and if they wanted to go to hospital #3 they would have to find their own doctor. The family did contact Cardiologist #2 who was a courtesy staff member at hospital #1.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.


Based on policy review, clinical record review and staff interview the facility failed to ensure that the patient/family was able to request or refuse treatment for one (1) of one (1) patient, Patient #1.

Findings:

Policy review " Patient Rights and Responsibilities " revealed " Your rights and responsibilities will include, but are not limited to: ...Refusal of treatment on religious or other grounds. "

On 06/09/10 Cardiologist #1 wrote orders for patient to be transferred to hospital #2 that owns/manages the current hospital (#1). The patient/family refused transfer. They requested transfer to hospital #3 instead where her oncologist and their family support were located. The attending hospitalist refused to transfer the patient to the patient/family requested hospital #3.

The family signed a consent for disposal of human remains to Funeral Home #1. During an interview the RN, Director of Acute Care Services on 07/28/10 she stated that the nursing staff did in fact call the wrong funeral home. The facility did not have a verification process in place nor did the nursing staff ask to see credentials of the funeral home personnel. The body was not released to the requested Funeral Home.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

Based on clinical record review and staff interview the facility failed to ensure that (1) one of (1) one patient was free from neglect.

Findings:

Clinical record review for Patient #1 revealed an admission date of 06/06/10 with a diagnosis of Congestive Heart Failure (CHF).

A cardiology consult was ordered due to the diagnosis of CHF. Cardiologist #1 had cared for Patient #1 on a previous admission. The consultation visit was made on 06/07/10 and the patient was determined to be stable with plans for a CT angiogram or heart catheterization to be performed at a later date as an outpatient.

Cardiology #1 progress report on 06/08/10 indicated " Doing better today with some back pains ...Potential outpatient catheterization Monday but if patient has problems can change to inpatient on Thursday instead. "

On 06/09/10 Cardiologist #1 wrote orders for patient to be transferred to hospital #2 that owns/manages the current hospital (#1). The patient/family refused transfer. They requested transfer to hospital #3 where her oncologist and their family support were located. The attending hospitalist refused to transfer the patient to the patient/family requested hospital #3. There is no documentation that Cardiologist #1 was consulted about the refusal to transfer to Hospital #2.

In an interview with the Registered Nurse (RN) Patient Care Coordinator (PCC), she stated that the hospitalist stated that he had already made arrangements to get the patient transferred to hospital #2 and if they wanted to go to hospital #3 they would have to find their own doctor. The family did contact Cardiologist #2 who was a courtesy staff member at hospital #1.

Patient #1 was evaluated on 06/10/10 by Cardiologist #2. Impression included: " 1. acute pulmonary edema; decompensated congestive heart failure, mildly depressed LVEF of 04/25/10; possible adriamycin cardiomyopathy; mildly elevated serum troponins. 2. Metastatic breast cancer, chemotherapy. 3. Abdominal pain; rule out small bowel obstruction. 4. Elevated BUN and creatinine; probable volume depletion. " Orders were written for transfer to Slidell Memorial Hospital to MICU.

The patient was never in ICU at hospital #1. During an interview with the hospitalist on 07/28/10 at approximately 9:50 a.m. he stated the patient was not sick enough to be in ICU, however she did require transfer to another hospital that provided a higher level of care. Her troponin and CPK levels were elevated on admission and continued to rise throughout the hospitalization. Renal function declined from BUN on admit 21 and Creatinine 1.1 to BUN 56 and Creatinine 2.5 on 06/10/10. Cardiac rhythm changes were also noted on 06/10/10 at 4:26 a.m., 07:00 a.m., and 14:53 p.m. There is no documentation that the RN notified the MD of the changes.

Prior to transfer to hospital #3 on 06/10/10 the patient ' s condition declined, requiring code status, intubation and transfer to ICU where she later died at 20:44 p.m. The family signed a consent for disposal of human remains to Funeral Home #1. During an interview the RN, Director of Acute Care Services on 07/28/10 she stated that the nursing staff did in fact call the wrong funeral home. The facility did not have a verification process in place nor did the nursing staff ask to see credentials of the funeral home personnel. The body was released to Funeral Home #2.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.

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

Findings:

Review of the medical record for Patient #1 ' s revealed that cardiac rhythm changes were noted on 06/10/10 at 4:26 a.m., 07:00 a.m., and 14:53 p.m. There is no documentation that the RN notified the MD of the changes.

These findings were discussed with the Interim Administrator and the Director of Nursing during the exit conference on 07/28/10 at approximately 2:30 p.m. No additional documentation was provided.