HospitalInspections.org

Based on document review and interview, in nine (9) of nine (9) grievances reviewed, it was determined the facility failed to conduct full and timely investigation of all complaints and grievances, consistent with The Centers for Medicare & Medicaid Services (CMS) guidelines. (Grievances 1-9).

Findings include:

The policy titled "Management of Patient Complaints and Grievances," last reviewed 02/16/2018, states, "all patients have the right to express complaints/grievances about the care and services they have received or are currently receiving and to have those complaints/grievances fully investigated and responded to in a timely manner..."

Review of a grievance for Medical Record (MR) #1 revealed in a letter dated June 24, 2019. The family complained that the on-call physician was at another hospital and he was only available for phone consultations; on 5/20/18 there was no doctor who was visible able to see her husband even though her husband's condition was "bad"; the doctor did not respond timely to the nurse's calls; the nurse did not activate a rapid response team; the family was never informed of his deteriorating and critical condition nor that the medicine that he was given would compromise his organs.

The facility documented their investigation on a facility form titled "Confidential Quality Assurance Document," which revealed the facility's investigation noted there was "no documentation to reflect the on-call physician's assessment on 5/21/18 am event regarding the patient's shortness of breath, and rapid Atrial Fibrillation which may result in the delay in the patient's intervention (intubation)."

There was no documented evidence that the facility investigated all of the complainant's allegations.

During an interview with Staff B, Associate Executive Director, conducted on 7/23/2021 at approximately 11:30 AM, she confirmed that the facility did not investigate all of the allegations in this complaint nor was a written response provided to the complainant.


Review of a grievance dated 5/4/2021 revealed an allegation that a nurse inappropriately touched a female patient while applying a urinary device. On 5/5/2021 the facility sent a letter to the grievant requesting additional time to investigate the allegation. On 6/11/2021 the facility completed the grievance investigation. On 6/15/2021 the facility sent out a letter to the grievant requesting additional time to complete the investigation. On 7/19/2021 the facility sent a final letter with the outcome of the investigation.

The facility documented the investigation was completed on 6/11/2021 and there was no documented response to the complainant with the outcome of investigation at that time. The facility requested additional time and sent the letter of a final outcome on 7/19/2021 which was more than 60 days after the complaint was made.

Similar findings were noted in seven (7) out 9 grievances reviewed where the facility failed to complete investigations of complaints within seven (7) days or as soon as possible, in keeping with CMS guidelines.

A review for the facility's policy titled, "Management of Patient's Complaints and Grievances," last reviewed 02/16/2018 states, a response will be provided within 7 calendar days of receipt of a grievance.

A) If the complexity of the grievance warrants further review, the seven (7) calendar day response will indicate additional time required to properly respond. The completed times frames will be provided set forth in this policy.

B) The patient or patient's representative will be informed of the need for additional time via documented phone call and/or written letter that the grievance is under review and a written response will be sent on or before 30 business days of receipt of the original grievance.

C) If a response cannot be sent within 30 business days of receipt of the grievance due to complexity of the grievance or extenuating circumstances in the resolution process, the patient or patient's representative will be informed of the need for additional time via documented phone call and/or written letter, and written response will be sent as soon as possible but not to exceed 60 business days for receipt of the original grievance."

The facility's policy allowing for 60 business days to resolve grievances does not meet CMS guidelines for grievances to be resolved as soon as possible.

These findings were shared during an interview with Staff B, Associate Executive Director which was conducted on 7/23/2021 at approximately 11:30 AM.

Based on medical record review, document review and interview, in two (2) of nine (9) grievances reviewed, it was determined the facility failed to provide a written response to complainants with the outcome of its investigation, investigative steps and the date of completion of its investigation. (Patients #1 and #2).

Findings include:

Review of a grievance dated 6/24/2019 revealed the family of Patient #1 complained that the on-call physician was at another hospital and he was only available for phone consultations; on 5/20/18 there was no doctor who was visible able to see the patient even though her husband's condition was "bad"; the doctor did not respond timely to the nurse's calls; the nurse did not activate a rapid response team; and the family was never informed of his deteriorating and critical condition or that the medicine that he was given would compromise his organs.

There was no documented evidence that the facility provided a written response to the complainant regarding these allegations.


Review of a document which was not dated nor titled, indicate a grievance (#2) from a mother who alleged a sexual encounter during her daughter's (MR #2) hospital admission of 12/16/2020 - 12/24/2020. The patient's brother was also very upset and appalled at the alleged event because his sister "was sick and not in her right mind."

Review of the facility's letter dated 1/14/2021 revealed the facility acknowledged the receipt of the complainant's letter and requested that a Health Insurance Portability and Accountability Act (HIPAA) form be completed.

There was no follow-up response to the complainants with the outcome of the investigation, investigative steps, and the date the investigation was completed.


The policy titled "Management of Patient Complaints and Grievances," which was last reviewed 02/16/2018 states, "A completed response to patient grievances will include:
-The contact person at the site
-The steps taken on behalf of the patient to investigate the grievance
-The results of the grievance process
-Date of completion."

During an interview with Staff B, Associate Executive Director, which was conducted on 7/23/2021 at approximately 11:30 AM, she confirmed that the facility did not provide a written response to the complainants noting the investigative steps that were taken, date of completion of the investigations, results of the investigations and a name of the hospital contact, as per policy.

Based on medical record review, document review and interview, in one (1) of 13 medical records reviewed, it was determined the facility failed to identify problem prone areas and failed to implement corrective actions to improve patient care (Patient #1).

Findings include:

The facility's Performance Improvement Safety Plan 2021 -2022 states, "our goal is to eliminate all preventable harm by delivering the safest healthcare with the lowest preventable mortality rates in the nation. Providing the best value to the communities we serve is a quality priority."

Review of the medical record for Patient #1 revealed there were multiple deficient findings related to the delivery of health care such as: failure to monitor and track the patient's weight on a daily basis; failure to order the frequency to monitor the patient's vital signs; failure of the nursing staff to escalate the patient's deteriorating condition on 5/20/2018 at 9:00 PM - 5/21/2018; and the failure of the on-call physician to assess and evaluate patient #1's deteriorating condition in a timely manner.

Review of a facility form titled, "Confidential Quality Assurance Document," revealed the facility conducted an investigation and identified that "there was no documentation to reflect the on-call assessment on 5/21/2018 am event regarding the patient's shortness of breath and rapid Atrial Fibrillation which may result in the delay in patient's intervention (intubation)."

There was no documented evidence that the facility implemented any system-wide corrective actions to prevent this event from reoccurring.

During interview conducted on 7/23/2021 at approximately 11:15 AM with Staff B, Associate Executive Director and Staff C, Medical Director, it was confirmed that they did not identify these concerns for delivery of care or initiated any actions to address all of these care issues.

Based on medical record review, document review and interview, in one (1) of 13 medical records (MR) reviewed, it was determined the medical staff failed to provide appropriate and timely medical care for a patient. Specifically, the medical staff failed to: (1) monitor a patient's weight gain despite the patient's diagnosis of volume overload, (2) write an order to monitor the patient's vital signs, (3) reassess the patient in a timely manner and (4) implement interventions in a timely manner when the patient's condition progressively deteriorated.
(MR #1).

These failures may have placed patients at risk for serious harm or death.

Findings include:

Review of the MR for Patient #1 identified: the patient was admitted to the facility on 5/8/2018. The admitting diagnoses included Pulmonary Congestion with volume overload, elevated BNP (test to measure heart failure) and Atrial Fibrillation. He was admitted to the Coronary Care Unit (CCU) and received medical care from multiple members of the medical staff. The medical staff included a cardiology attending, pulmonary attending, critical care residents and attendings, infectious disease attending and internal medicine attending physicians.

The medical staff failed to: monitor the patient's weight on a daily basis, write an order for monitoring the patient's vital signs, reassess the patient in a timely manner when the patient's condition deteriorated after 9:00 PM on 5/20/2018, and they did not intubate the patient until 8:58 AM on 5/21/2018, nine (9) hours after his condition began to deteriorate.

See findings at A 0347.

Based on medical record review, document review and interview, in one (1) of 13 medical records (MR) reviewed, it was determined the medical staff failed to provide appropriate and timely medical care for a patient. Specifically, the medical staff failed to: (1) monitor a patient's weight gain, (2) write an order to monitor the vital signs, (3) reassess the patient in a timely manner and (4) implement interventions in a timely manner when the patient's condition progressively deteriorated. (MR #1).

Findings include:

1. Review of medical record for Patient #1 identified a 77-year-old patient who presented to the Emergency Department (ED) on 5/8/2018 at 5:34 AM with a complaint of difficulty breathing. EMS found the patient that morning with shortness of breath with an oxygen saturation of 79%. Patient also had exertional dyspnea, orthopnea, shortness of breath and peripheral edema. His vital signs upon presentation at 5:34 AM were heart rate 122 (normal 60-100), respirations 22 (normal 12-20), blood pressure 138/96 (normal 90-120/50-90) and the oxygen saturation was 94% (normal 96% - 100%). The patient was placed on CPAP (oxygen). He was alert and oriented to person, place, time, and situation.
The patient was diagnosed with Pulmonary Congestion with volume overload, elevated BNP (test to measure heart failure) and Atrial Fibrillation and he was admitted to the Intensive Care Unit (ICU).

The patient's weight on admission 5/8/2018 was 276 lbs. The doctor ordered daily weights on 5/8/2018. On 5/12/2018, the patient's weight was 274 lbs. and it increased to 288.8 lbs. on 5/13/2018. This was a 14 lb. weight gain during this period.

There was no documented evidence in the medical record that a physician monitored and evaluated the patient's weight, from 5/14/2018 until 5/21/2018, the morning that the patient's condition progressively deteriorated.


2. There is no documented evidence that the medical staff wrote an order indicating timeframes for monitoring the patient's vital signs. For example:

On 5/20/2018 at 8:52 PM when there was a change in the patient's condition, heart rate was 125, respiration 26 and oxygen saturation was 95%. The patient's vital signs was reassessed two (2) hours later at 10:52 PM, indicating the heart rate was 120, respirations had increased to 33 and the oxygen saturation had decreased to 92%.

At 11:13 PM, the respiration was 28, it was again reassessed almost 2 hours later at 12:52 PM, indicating the respiration was 38.

On 5/20/2018 at 12:52 PM, patient's blood pressure (B/P) was 114/87. The B/P was again checked at 4:52 AM, four (4) hours later, and was 137/99.
On 5/21/2018, patient's heart rate was documented at 1:20 AM as Atrial Fibrillation 110's - 130's. At 4:00 AM that morning, more than three (3) hours later, heart rate 126 was next documented.


3. The documentation of the medical care and treatment included: On 5/19/18 at 9:04 AM, the cardiologist documented that the patient still had shortness of breath and the prognosis was guarded. He also documented that the patient may need intubation.

On 5/20/2018 at 7:07 PM, a nurse documented patient's oxygen saturation was 83%, and at 8:02 PM, the patient had frequent and dry cough, dyspnea on exertion and retractions. At 9:00 PM, the nurse documented that the patient "was anxious, he was unable to rest" and that the doctor was informed of the patient's condition at 9:00 PM that night. "Unable to tolerate being off Bipap for short periods of time for mouth care. The on-call doctor ordered Morphine x 1 dose" which was given at that time."

There was no evidence in the medical record that the patient was assessed by the physician at that time.

On 5/20/2018 at 10:52 PM, a Patient Care Assistant documented that the patient's heart rate was 120, respiration 33 and the oxygen saturation was 92%, down from 97% the previous day.

On 5/21/2018, the nurse documented the physician was contacted at 1:20 AM because the patient had uncontrolled Atrial Fibrillation ranging from 110's - 130's.

On 5/21/2018 at 3:38 AM, the nurse documented that she again contacted the doctor at 2:30 AM that morning because of the patient's condition and that there were no new orders. "The patient was short of breath, anxious and complained of the inability to rest. Pulse oximeter 90% - 93%. Morphine was again given stat" according to the physician's order.

At 4:06 AM, the nurse documented that the patient's nails were dusky, pale, and the patient's breathing remained labored.

At 4:47 AM the nurse documented that the doctor was at the patient's bedside. The patient's heart rate was 120's - 140's and there was uncontrolled Atrial Fibrillation. The patient complained of anxiety and discomfort. The oxygen saturation was 90-92% on 100% high flow oxygen via Bipap.

At 4:52 AM the nurse documented that the heart rate was 139, the respiration was 26 (normal 12-20) and the blood pressure was 139/99.

There was no documentation that the physician performed an assessment or made any changes in the patient's management/treatment at 4:47 AM.

At 6:38 AM that morning, an EKG showed the patient's irregular heart rate had progressed to Atrial Fibrillation with rapid ventricular response with the heart rate at 127 beats per minute.

There is no documentation that the medical staff evaluated the patient when the patient developed Atrial Fibrillation with Rapid Ventricular Response at 6:30 AM that morning.

At 7:13 AM, a nurse documented vital signs, the patient's heart rate was 141 (normal 60-100) and respiration 36 (normal 12-20).

At 7:20 AM, the nurse documented, patient was still dusky and pale, dyspneic and the rhythm and pattern of breathing was not normal.

The on-call physician failed to assess the patient after 9:00 PM on 5/20/2018, when the nurse informed him that the patient's condition began to deteriorate.
The medical staff failed to evaluate the patient when the Atrial Fibrillation worsened at 1:20 AM on 5/21/2018
There was no documentation that the physician performed an assessment or made any changes in the patient's management/treatment on 5/21/2018 at 4:47 AM, when the nurse documented the physician was at the bedside.


4. On 5/21/2018 at 4:06 AM, the nurse documented that the patient's nails were dusky, pale, and the patient's breathing remained labored.
At 4:47 AM the nurse documented that the doctor was at the patient's bedside. The patient's heart rate was 120's - 140's and there was uncontrolled Atrial Fibrillation. The patient complained of anxiety and discomfort. The oxygen saturation was 90-92% on 100% high flow oxygen via Bipap.

On 5/21/2018, a cardiologist documented at 8:46 AM that morning that the "patient needs to be intubated."
At 8:50 AM, a nurse documented that the respiratory rate was 40, heart rate 142 and the oxygen saturation was 79%.
The patient was intubated at 8:58 AM that morning, and he sustained a cardiac arrest 28 minutes later at 9:26 AM. During intubation, dried blood was seen on his vocal cords. Advanced Cardiac Life Support interventions were unsuccessful, and the patient was pronounced dead at 9:56 AM that morning.

The facility's investigation documented on a form titled "Confidential Quality Assurance Document," revealed there was "no documentation to reflect the on-call physician's assessment on 5/21/18 am event regarding the patient's shortness of breath, and rapid Atrial Fibrillation which may result in the delay in the patient's intervention (intubation)."

During an interview with Staff C, Medical Director, which was conducted on 7/23/2021 at 11:15 AM, he confirmed that the patient could have been intubated earlier and that there was inconsistency among the medical staff regarding the need for intubation and the care and management of the patient.

The Autopsy Report revealed findings included pulmonary congestion, pulmonary edema and pulmonary hemorrhage.

Based on medical record review, document review and interview, in one (1) of 13 medical records (MR) reviewed, it was determined the nursing staff failed to (1) follow a physician's order to weigh a patient on a daily basis, (2) formulate procedures for patients whose condition is deteriorating in the Critical Care Unit, and (3) modify a patient's nursing care plan when a patient's condition deteriorated. (Patient #1).

These failures may have placed the patient at risk for serious harm or death.

Findings include:

1. Review of MR for Patient #1 identified: The patient was admitted to the facility on 5/08/2018 with diagnoses that included Congestive Heart Failure and Volume Overload. The physician ordered daily weights on 5/8/2018. There was no documented evidence that the nursing staff weighed the patient from 5/14/2018 until 5/21/2018, the morning that the patient's condition progressively deteriorated.

See detailed findings at A 0395.

2. The facility does not have a current procedure for patients' whose condition deteriorate in the critical care units, as stated in their policy titled "Rapid Response Activation."

Patient #1's condition began to deteriorate on 5/20/2018 at 9:00 PM, evidenced by increasing shortness of breath, labored breathing, change in skin color (dusky and pale), anxiousness, increased respiratory rate and increased abnormal heart rhythm. The on-call physician was contacted on multiple occasions on 5/20/2018, from 9:00 PM until approximately 4:30 AM on 5/21/2018, as per nursing documentation. The on-call physician did not assess the patient throughout the night.

The facility's policy titled "Vital Signs for Adult and Pediatric Patients" which became effective 6/21/2018 does not provide guidelines or timeframes for monitoring of vital signs on the Inpatient Units and the Emergency Department.

See detailed findings at A 395.

4. There was no documented evidence that the nursing staff modified Patient #1's nursing care plan when his condition progressively worsened the night of 5/20/2018.

See detailed findings at A 0396.

Based on medical record review, document review and interview, in one (1) of 13 medical records (MR) reviewed, it was determined the nursing staff failed to (1) follow a physician's order to weigh a patient on a daily basis, (2) formulate a procedure for patients' whose condition is deteriorating in the Critical Care Units, and (3) formulate a policy for reassessment of patients' vital signs. (Patient #1).

Findings include:

1. Review of the MR for Patient #1 revealed: the patient was admitted on 5/8/2018 at 5:34 AM with diagnoses of Volume Overload, Shortness of Breath and Congestive Heart Failure. The physician wrote an order on 5/8/2018 at 9:38 AM for daily weights. The patient's weight was 276.6 lbs. on 5/8/2018. The nursing staff weighed the patient on a daily basis up to 5/13/2018. On 5/12/2018 the patient's weight was 274 lbs. On 5/13/2018 the patient's weight was 288.8 lbs. There was a 14 lb. weight gain between 5/12/2018 and 5/13/2018.

There was no documented evidence in the medical record that a member of the nursing staff monitored and evaluated the patient's weight from 5/14/2018 until 5/21/2018, the morning when the patient's condition deteriorated.


2. Review of the medical record for Patient #1 identified: On 5/20/2018 at 7:07 PM, a nurse documented patient's oxygen saturation was 83%, and at 8:02 PM, that the patient had frequent and dry cough, dyspnea on exertion and retractions. At 9:00 PM, the nurse documented that the patient "was anxious, he was unable to rest" and that the doctor was informed of the patient's condition at 9:00 PM that night. "Unable to tolerate being off Bipap for short periods of time for mouth care. The on-call doctor ordered Morphine x 1 dose" which was given at that time."

On 5/20/2018 at 10:52 PM, a Patient Care Assistant documented that the patient's heart rate was 120, respiration 33 and the oxygen saturation was 92%, down from 97% the previous day.
On 5/21/2018, the nurse documented the physician was contacted at 1:20 AM because the patient had uncontrolled Atrial Fibrillation ranging from 110's - 130's.
On 5/21/2018 at 3:38 AM, the nurse documented that she again contacted the doctor at 2:30 AM that morning because of the patient's condition and that there were no new orders....
4:06 AM, the nurse documented that the patient's nails were dusky and pale, and the patient's breathing remained labored.
At 4:47 AM the nurse documented that the doctor was at the patient's bedside. The patient's heart rate was 120's - 140's and there was uncontrolled Atrial Fibrillation. The patient complained of anxiety and discomfort. The oxygen saturation was 90-92% on 100% high flow oxygen via Bipap.
At 4:52 AM the nurse documented that the heart rate was 139, the respiration was 26 (normal 12-20) and the blood pressure was 139/99.
At 6:38 AM that morning, an EKG showed the patient's irregular heart rate had progressed to Atrial Fibrillation with rapid ventricular response with the heart rate at 127 beats per minute.
At 7:13 AM, a nurse documented vital signs, the patient's heart rate was 141 (normal 60-100) and respiration 36 (normal 12-20).

The patient was intubated at 8:58 AM that morning, and he sustained a cardiac arrest 28 minutes later at 9:26 AM. Advanced Cardiac Life Support interventions were unsuccessful, and the patient was pronounced dead at 9:56 AM that morning.

The condition of this CCU patient began to deteriorate after 9:00 PM on 5/20/2018, and cardio-pulmonary interventions were not initiated timely. The patient was intubated at 8:58 AM on 5/21/2018, nine (9) hours after his condition began to deteriorate. He sustained a cardiac arrest 28 minutes later at 9:26 AM. Advanced Cardiac Life Support interventions were unsuccessful, and the patient was pronounced dead at 9:56 AM that morning.

The policy titled Rapid Response Activation, which was effective 5/15/2011, states the criteria for Activation of Rapid Response include heart rate >130 per minute or respiration >28 per minute. The policy also states, "the Rapid Response Team will not cover" the patients on these units, "ICU, CCU, CTU and Burn Unit - these units have a current procedure to provide coverage for these patients."
This policy was not reviewed and/or revised since 2011, more than ten years ago.

During an interview with Staff D, Nurse Manager ICU/CCU, which was conducted on 7/23/2021 at 2:20 PM, staff was asked about activation of the Rapid Response in the CCU. Staff stated the facility's procedure when patient's condition deteriorate was to call the doctor and that "there was no current procedure" when patients' condition deteriorate as stated in the Rapid Response Activation policy.

There was no current procedure for patients' when their condition deteriorated in the ICU, CCU, CTU and Burn unit as stated in this policy.


3. The patient's heart rate on 5/20/2018 at 8:52 PM was 125, the respiration 26 and the oxygen saturation was 95%. Patient was reassessed two (2) hours later at 10:52 PM, indicating the heart rate was 120, respirations had increased to 33 and the oxygen saturation had decreased to 92%.
At 11:13 PM the patient's respiration was 28. Respiration was again reassessed almost 2 hours later at 12:52 PM, despite the patient's deteriorating condition, indicating the respiration was 38.
Patient's blood pressure was checked at 12:52 PM on 5/20/2018 and was 114/87. It was checked again at 4:52 AM (four (4) hours later) and was 137/99.
Patient's heart rate was documented at 1:20 AM on 5/21/2018 as Atrial Fibrillation 110's - 130's. The heart rate was next documented at 4:00 AM, more than three (3) hours later, that the heart rate was 126.

Review of the policy titled "Vital Signs for Adults and Pediatric Patients," which was last reviewed 6/21/2018, states, "all patients should have a complete set of vital signs taken and documented during their Emergency Department visit. All patients will have vital signs taken and documented prior to admission, discharge (if clinically warranted) and transfer."

The policy does not provide guidelines or timeframes for monitoring of vital signs on the inpatient units and throughout the hospital.

The policy does not provide timeframes for reevaluating or monitoring vital signs for patients during the patients' ED visit when applicable.

These findings were shared with Staff B, Associate Executive Director on 7/23/2021 at 3:30 PM.

During an interview with Staff D, Nurse Manager ICU/CCU, conducted on 7/23/2021 at 2:20 PM, she stated vital signs should be monitored every two (2) hours in the Critical Care Units.

The nursing staff did not formulate a policy to provide guidance for timely reassessments of all the patients' vital signs in the Critical Care Units.

Based on medical record review, document review and interview, in one (1) of 13 medical records reviewed, it was determined the nursing staff failed to revise the patient's care plan when his condition deteriorated. (Patient #1).

Findings:

Review of Medical Record for Patient #1 revealed, the patient was admitted on 5/8/2018 with diagnoses of Fluid Overload, Shortness of Breath and Congestive Heart Failure. A nurse documented on 5/20/2018 at 9:00 PM, that the on-call doctor was contacted because there was a change in the patient's condition. She also contacted the physician at 1:20 AM and 2:30 AM on 5/21/2018 when the patient's condition continued to deteriorate, evidenced by decreasing oxygenation, increasing irregular heart rate, labored respirations, and decreased oxygenation because the patient had a dusky, pale color.

The surveyor requested the nursing care plan policy on 7/22/2021, and on 7/23/2021 at approximately 2:00 PM, Staff D, Nurse Manager ICU/CCU provided a policy titled "Knowledge-Based Charting (KBC) Documentation" as the nursing care plan.
The policy states, "the purpose of this policy is to describe the nursing responsibilities required to provide a complete picture of the patient's individualized plan of care, the care provided and patient/family education by documentation in the legal medical record." It also states, "the plan of care may be initiated, amended or updated by clinicians of any discipline involved in the care."

There was no evidence in the medical record that the nursing staff updated the care plan and established new goals when the patient's condition began to deteriorate after 9:00 PM on 5/20/2018.

These findings were shared with Staff B, Associate Executive Director on 7/23/2021 at 3:30 PM.