HospitalInspections.org

Based on document review, record review and staff interview it was determined the Emergency Department (ED) Nurse Manager failed to follow the hospital's policy for filing a patient's complaint in five (5) of five (5) records review with patients who complained through the ED patient call back program (patients #7, 8, 11, 12 and 13). This failure has the potential to adversely impact all patients who wish to file a complaint or grievance.

Finding include:

1. Review of the policy titled "Complaint Grievance Process Policy", last revised 11/30/16, revealed it states, in part: "CMS Interpretive Guidelines 482.13 (a)(2): The patient should have a reasonable expectation of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner...Complaints may be received anonymously or from patient/family satisfaction surveys...When a complaint/grievance is initiated, the event report-complaints and grievances is utilized by staff receiving the complaint/grievance and then forwarded to the risk manager."

2. Review of the document titled "Patient Dissatisfaction", with dates from 11/19/16 through 1/22/17, revealed patient #7 voiced a complaint when she was contacted by the hospital regarding her ED visit on 1/2/17. The document stated: "She came to the ED because her physician wanted her to be transferred to Memorial Hospital and the physician wouldn't transfer her." No complaint or event report was filed per hospital expectations and policy.

3. Review of the document titled "Patient Dissatisfaction", with dates from 11/19/16 through 1/22/17, revealed the hospital contacted patient #8 regarding an ED visit on 1/1/17. The hospital spoke with the patient's mother and the document stated: "The mother complained that her child's blood culture came back contaminated and her C-diff stool culture was labeled wrong and the test was not completed." No complaint or event report was filed per hospital expectations and policy.

4. Review of the document titled "Patient Dissatisfaction", with dates from 11/19/16 through 1/22/17, revealed patient #11 voiced a complaint when he was contacted by the hospital regarding his ED visit on 1/9/17. The document stated: "The physician gave him medication for his diagnosis that he was allergic to and if the physician would have looked at his chart he wouldn't have went home with the wrong medication." No complaint or event report was filed per hospital expectations and policy.

5. Review of the document titled "Patient Dissatisfaction", with dates from 11/19/16 through 1/22/17, revealed patient #13 voiced a complaint when he was contacted by the hospital regarding his ED visit on 12/17/16. The document stated: "He wasted his time coming to the ED for his wound, and had to go to his doctor to get his wound checked and cut open." No complaint or event report was filed per hospital expectations and policy.

6. An interview was conducted with the Director of the ED on 5/1/17 at 1:22 p.m. When asked to explain the procedure of retrieving complaints from the ED call back program, she stated, in part: "If I get the complaint I forward them to the (Risk Manager)." When shown the patient call back log of patient dissatisfaction and asked if the complaints were forwarded to the Risk Manager, she stated, in part: "No, I didn't know about the complaints because I didn't know I could retrieve them." When asked if she followed the policy for filing a complaint, she stated, "No, I didn't know about the complaints."

7. An interview was conducted with the Director of Nursing on 5/2/17 at 8:15 a.m. After reviewing the information on the patient dissatisfaction report and discussing the information with the ED Nurse Manager she concurred with the above findings.

A. Based on document review, record review and staff interview it was determined the medical-surgical Nurse Manager failed to ensure a Registered Nurse (RN) completed an accurate head-to-toe assessment every shift on one (1) of (1) patients admitted for observation (patient #6). This failure has the potential for all patients to not be accurately assessed by an RN.

Findings Include:

1. Review of the policy titled "Daily Nursing Assessment", last reviewed 12/11, revealed it states, in part: "The daily nursing assessment is completed by the nurse on each shift (RN/LPN). If the LPN collects data for assessment the RN will review the assessment and complete areas not performed by the LPN...Risk factors for skin impairment will be assessed each shift and documented."

2. Review of the medical record for patient #6 revealed the patient was placed on observation on the medical-surgical unit on 1/11/17 at 10:30 p.m. An initial assessment was completed by an RN but she failed to complete a head-to-toe assessment that would have included a dressed wound to the patient's left lower thigh. The medical record further revealed only one (1) other assessment during the patient's hospitalization was completed by an RN on 1/13/17 at 9:40 p.m.

3. An interview was conducted with the Nurse Manager of the medical-surgical unit on 5/1/17 at 250 p.m. When asked if Licensed Practical Nurses (LPN) complete assessments on patients, she stated, in part: "Yes, an RN assesses once every 24 hours and then the LPN can assess the patient."

4. Review of the scope of practice for an LPN in West Virginia (WV Code §30-7A-1), last reviewed 4/5/15, revealed it states, in part: "A LPN means the performance for compensating selected nursing acts in the care of the ill, injured or infirm under the direction of a registered professional nurse or licensed physician...and not requiring the substantial specialized skill, judgement and knowledge required in professional nursing."

5. An interview was conducted on 5/2/17 at 2:29 p.m. with the Director of Nursing. When asked if an LPN can assess a patient, she stated, "An LPN can document but not assess a patient." She concurred with the above findings.

B. Based on document review, record review and staff interview it was determined the medical-surgical Nurse Manager failed to ensure a Registered Nurse (RN) completed an accurate head-to-toe assessment every shift on one (1) of (1) patients admitted for observation that was admitted with a wound (patient #6). This failure has the potential for all patients to not be accurately assessed by an RN for treatment of a wound.

Findings include:

1. Review of the policy titled "Pressure injury and wound risk assessment prevention and treatment" revealed it states, in part: "Wound assessment is conducted using the anatomical man wound and incision assessment...assessment includes type of wound, size and location of wound, appearance, drainage and appearance of the surrounding skin. Photographs will be taken of any reddened area or wound on admission, discharge with any significant change and weekly... Scope of practice, RN admission and daily assessment...the RN is also accountable for the implementation of the skin/pressure injury prevention protocol and wound care.

2. Review of the medical record for patient #6 revealed the patient was placed on observation on the medical-surgical unit on 1/11/17 at 10:30 p.m. An initial assessment was completed by a registered nurse but she failed to complete a head-to-toe assessment that would have included a dressed wound to the patient's left lower thigh.

3. Review of the medical record for patient #6 revealed on 1/12/17 at 4:39 p.m. Licensed Practical Nurse (LPN) #1 documented: "This nurse was talking to patient's sister who is in the room visiting that he had a dressing on a wound on his left upper thigh twice a day and that she had just redressed it with idoform and wrapped in gauze and this nurse didn't see it earlier because the patient had shorts on...Dr. #1 notified." No measurements were noted and no pictures were taken of the wound.

4. Review of the medical record for patient #6 revealed on 1/13/17 at 2:00 p.m. LPN #2 documented: "Pt's sister verbalized to me that the pt. is to be having dressing changes performed...Dr. #2 notified and dressing changed ordered." LPN #2 documented a dressing change but no measurements were noted and no pictures were taken of the wound.

5. Review of the medical record for patient #6 revealed there was no further documentation of wound care.

6. An interview was conducted on 5/2/17 at 2:29 p.m. with the Director of Nursing and she concurred with the above findings.