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Tag No.: A0123
Based on interview and record review, the facility failed to provide the Patient's Representative with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 Patient's reviewed (Patient #1) with a grievance lodged by his representative/spouse on 6/21/17. Specifically,
As of 10/25/17, Patient #1's representative/spouse had not received resolution of her grievance, or a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Grievance policy.
This deficient practice affected Patient #1's rights when the facility failed to communicate the outcomes to Patient #1's representative/spouse regarding the concerns, complaints, and grievance expressed on behalf of Patient #1's rights, treatment, and satisfaction.
Findings included:
Complaint # TX 00268785.
Review of the facility's Patient Complaint and Grievance Process Policy revised 01/25/17 revealed the following, in part:
A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation or accrediting organization standards.
Procedures included:
L. The patient will be provided with written notice of:
1. The name of the Patient Advocate
2. The steps taken to investigate and resolve the grievance
3. The final result of the complaint and grievance process
4. The date of completion of the complaint and grievance process.
Record review of the facility's Grievances and Complaints revealed on 6/21/17 the facility's Chief Nursing Officer (CNO) received a complaint in person by Patient #1's representative/spouse alleging quality of care issues, and facility neglect regarding his medical diagnosis of hypertension and diabetes. Further review revealed Patient #1's representative/spouse was "very upset, stating her husband could have died here and that he was our responsibility while he was inpatient with us." Further review in the area of problem resolution/follow-up; the Patient Advocate documented that she informed Patient #1's representative/spouse that she would "look into everything that we discussed and get back with her after I had some information for her. She understands that I need to research what happened and is not holding me to a time frame. Letter sent 6/27/17 to [Patient #1's representative/spouse] informing her of the investigation and that food was offered and declined. Once the investigation has concluded she will be notified of the outcome.
Review of the letter dated 6/26/17 to Patient #1's representative/spouse from the facility's Patient Advocate indicated the issues described, including the concerns about the medical treatment Patient #1 received and the admissions process would be reviewed. "Once our investigation is complete, we will inform you of the results."
Further review of the facility's documentation and evidence provided regarding this specific complaint/grievance revealed Patient #1's representative/spouse was not provided with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Complaint and Grievance Process Policy.
During an interview on 10/25/17 at 1:55 PM with the Patient Advocate (PA) stated she and the Director of Risk Management/Performance Improvement (DRM/PI) met with Patient #1's representative/spouse regarding her complaints/grievance. The PA confirmed a written response had not been sent to Patient #1's representative/spouse regarding her allegations/complaints that included; steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's policy because Patient #1's representative/spouse stated she did not want a follow-up letter after the investigation. The PA confirmed the facility's process and procedures for response to Grievances included a response to include; the steps taken to investigate, and the results of the investigation; The PA confirmed the facility's Grievance policy included a written response to the complainant that provided adequate information to address the complaints.
During an interview on 10/25/17 at 3:45 PM with Patient #1's representative/spouse stated she had not received any follow up information or a letter from the facility after the investigation was completed. She said she only received the letter dated 6/26/17 as indicated above. She stated that she met with the CNO and the PA initially; and understood her complaints/grievance would be investigated. Patient #1's representative/spouse stated that she did not tell the facility staff that she did not want a follow-up letter with the results of the investigation. She further expressed that she felt staff would "blow me off" when trying to address her concerns/complaints expressed.
Tag No.: B0122
Based on record review and interview, the facility failed to ensure the written master treatment plan (MTP) for 1 of 1 Patient's reviewed (Patient #1) included interventions with specific treatment modalities to address the patient's identified problems.
Specifically, Patient #1's MTP had medical problems identified during admission assessment for Hypertension (HTN) and Diabetes Mellitus (DM); but facility staff failed to order Patient #1's routine medications and/or document other appropriate treatment interventions to address the patient's HTN and DM. As a result, Patient #1 was transferred out to another Emergency Facility on 6/17/17, and again on 6/19/17 for the management of his HTN that was uncontrolled.
Findings included:
Review of the complaint intake information for TX00268785 revealed Patient #1's representative/spouse made a complaint that during the admission process the facility took over 10 hours to complete the admission process. During this admission process; Patient #1's representative/spouse told the admission facility staff several times that he had not eaten; needed food and his medications for HTN (high blood pressure) and his diabetes. As a result, Patient #1 was sent out to an Emergency Facility due to his blood pressure was too high for the facility to admit him. After admission, Patient #1's representative/spouse stated the facility did not order his regular blood pressure medications upon admission and once again; on 06/19/17, Patient #1 was sent out to an Emergency Facility due to his blood pressure was too high, and the facility could not manage it at that point.
Record review of Patient #1's Master Treatment Plan (MTP) dated 6/17/17 included problem list, "2. Altered cardiac output, 3. Diabetes Mellitus (DM). Medical problems included hypertension and DM. Further review revealed "Medical Problem Sheet" for #2, Altered Cardiac Output- for Hypertension revealed the intervention was blank. There was an area for nursing interventions, and an area for Physician interventions which included medications ordered for treatment of the hypertension that were all blank.
Review of the Medical Problem Sheet for #3, Diabetes revealed the intervention was blank. The area for nursing interventions and physician interventions were blank for treatment.
Review of the History and Physical (H&P) Examination Assessment dated 6/17/17 revealed the physician documented Essential HTN and DM type 2. In the area of "Plan of Care" revealed for HTN was to continue home medications. For the DM- type 2 indicated continue metformin, glipizide. Further review of the Physician Orders revealed there were was not any medications ordered for the Essential HTN until 6/19/17 when Patient #1's Blood Pressure was not controlled. As a result, on 6/19/17 Patient #1 was sent out to an Emergency Facility for intervention for a second time since admission.
During an interview on 10/25/17 at 12:45 PM with the facility's Medical Director stated the physician that completed Patient #1's H&P on 6/17/17 failed to follow-up with Patient #1's home medications and the admitting "Telemed" physician's assessment. The Medical Director stated usually the admitting physician will address the medical problems list by ordering medications and interventions but it was determined verification needed to be done with the inpatient attending physician for medication dosing's and reconciliation in accordance with the Patient's home meds. The Medical Director confirmed that Patient #1's MTP was blank for nursing and physician interventions regarding treatment of Patient #1's HTN and DM. The Medical Director stated Patient #1's HTN was not addressed or initiated until 6/19/17 when it was uncontrolled; and then Patient #1 had to be transferred out to an Emergency Facility. The Medical Director further stated that the facility has since changed providers due to problems with orders and interventions.
Tag No.: B0137
Based on interview and record review, the facility failed to ensure adequate numbers of qualified professional, technical, and consultative personnel were available in the admissions area to evaluate patients in a timely manner during the admission assessment and diagnostic data gathering.
Specifically, on 6/17/17 Patient #1 was transferred from a hospital facility following medical clearance for psychiatric treatment. The facility failed to have sufficient staffing in the admissions area and Patient #1 was in the admission work-up area for assessment and diagnostics for over 10 hours without a substantial meal and his routine home medications ordered for treatment of his Hypertension (HTN) and Diabetes Mellitus (DM). As a result, Patient #1 was sent out to an Emergency Facility after 10 hours; due to his blood pressure/HTN was too high for the facility to admit and manage.
Findings included:
Review of Patient #1's medical records revealed the following:
1.) Arrival time to the facility was 6/16/17 at 04:30 PM. Patient #1 arrived as a transfer from another hospital facility for psychiatric treatment following medical clearance.
2.) Medical Screening Examination completed at 6/17/17 at 01:55 AM (over 9 hours after arrival) revealed blood pressure was 211/117.
3.) Memorandum of Transfer revealed Patient #1 was sent out by Ambulance to an Emergency facility at 02:45 AM on 6/17/17 for HTN uncontrolled.
Review of the complaint intake information for TX00268785 revealed Patient #1's representative/spouse made a complaint that during the admission process the facility took over 10 hours to complete the admission process. During this admission process; Patient #1's representative/spouse told the admission facility staff several times that he had not eaten; needed food and his medications for HTN (high blood pressure) and his diabetes. As a result, Patient #1 was sent out to an Emergency Facility due to his blood pressure was too high for the facility to admit him.
During an interview on 10/25/17 at 12:20 PM with the Admissions Director (AD) stated all admission times were tracked and that the overall goal for times in admissions was 120 minutes (2 hours). The AD stated the overall average time for all patients in June 2017 was 167 minutes (2 hours, and 47 minutes). The AD stated there were multiple factors for admissions times which included patient acuity, the number of patients in admission area for assessment, and facility staffing. The AD indicated he is evaluating their current systems and looking at their processes in order to present corrective actions to their new Chief Executive Officer. The AD confirmed 10 hours for the admission process was not acceptable and unusual.
During an interview on 10/25/17 at 12:55 PM with the Assistant AD stated specifically on 6/16/17 (Friday afternoon) at 04:30PM; when Patient #1 presented to admissions there were 10 patients in the admissions area for assessments and only one registered nurse, and one therapist present until 10:00 PM; when the swing shift/transition shifts occur. The Assistant AD stated on 6/16/17 two staff were "call-offs" and did not show up to work; which was a clerk and a therapist. The Assistant AD further stated there had been a RN vacancy position at the time as well; which accounted for 3 less staffing overall on this date and time. The Assistant AD stated there was a PRN (as needed) pool staffing list to call; but that no one came in that day to assist. The Assistant AD further indicated they were supposed to inform the house supervisor and nurse managers when there was a shortage of staff in admissions in order to send staff from the units to assist. The Assistant AD confirmed no staff came from the units to assist in admissions on this date.