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Based on interview, record review, review of the facility's policy and review of grievance documents it was determined the facility failed to ensure written notice was provided for one (1) of nineteen (19) sampled patients (Patient #16) after a grievance was filed with the facility.

The findings include:

Review of the facility's policy A01-025, "Patient Complaints and Grievances", dated 12/08 revealed a Customer Service Representative (CSR) was to "facilitate communication between the prinicipals to resolve the problem. The CSR will remain in contact with the complainant regarding the status of the grievance via phone and written correspondence...The CSR will attempt to contact the complainant to ensure that the grievance has been resolved to the patient's satisfaction...Any grievance unresolved after seven days will be reviewed every 14 days by the manager of Customer Service and/or Director of Customer Service" until satisfaction is achieved. "Resolution of grievances should not exceed 90 days".

Review of Patient #16's medical record revealed an admission date of 02/10/11, and diagnoses that included fractures of the tibia and fibula (bones in the lower leg). Review of the record revealed the patient was taken to surgery for an intramedullary nailing of the right tibia fracture. Review of the face sheet revealed the patient had a Power of Attorney (POA). Further review of the record revealed the patient expired on 03/18/11.

Interview, on 02/01/12 at 9:30 AM, with the POA revealed he/she had filed a grievance with the facility related to the patient being overmedicated, however never received a response.

Review of the Grievance "Service Management" form revealed the Patient #16's POA filed a grievance on 03/14/11, related to the patient being "overmedicated" in February 2011, and he/she requested the facility pay for Patient #16's "airlift" back home to another state. Continued review of this form revealed the grievance was referred to Risk Management and the "Status" was documented as "closed". Further review revealed no documented evidence an investigation into the POA's grievance, related to his/her concerns the patient was overmedicated, was performed or that written notice containing the regulatory requirements of name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was sent to the POA.

Interview, on 02/06/12 at 2:25 PM, with the Clinical Risk Manager revealed the complaint was received "last March" (03/11) that there was a medication error. She stated before an indepth investigation could be completed Patient #16 had a cardiac arrest and subsequently died. She stated the facility's policy was to investigate patient/family complaints, then "Customer Service" sends the patient/family a "closure" letter. In another interview, on 02/07/12 at 4:20 PM, the Clinical Risk Manager stated the facility failed to "close the loop" in regards to Patient #16's POA's grievance. She stated she could not find where a closure letter was sent to the POA. The Clinical Risk Manager stated an investigation was never completed into the POA's grievance related to Patient #16 being overmedicated. Additionally, she stated the facility thought the concern had changed after the patient died.

Interview, on 02/07/12 at 4:00 PM, with the Interim Director of Accreditation and Regulatory Compliance revealed "there could be improvements" made in the facility's grievance process.

Based on observation, interview, andthe facility's policy review, it was determined the facility failed to ensure patient clinical records were kept confidential for three (3) unsampled patients. Clipboards containing personal information regarding patients was in a public corridor and available for the general public to see.

The findings include:

Review of facility's policy, Confidentiality Policy #A06-045, revision/review date of 07/2011 revealed, "...provide guidelines for person who have access to patient information so that the patient's protected health information remains private and confidential." Further review of the policy revealed item number four (4) under the procedure heading stated, "caregivers shall not share IDs and passwords. Additional review of the policy revealed number sixteen (16) to state, "...caregivers shall turn over clipboards and charts handing in public areas and hallways so the patient information may not be seen."

During the initial tour of the facility, on 02/02/12, an observation was made of clipboards with report sheets lying on the nursing work stations uncovered and revealing patient information. This area was known as a public corridor. Information included on the sheet included: name of patient, room number, height and weight, allergies, age, contact information and passwords, history, current diagnosis, injuries, procedures, and system concerns.

Interview on 02/02/12 at 3:15 PM, with Registered Nurs (RN) #1/Unit Director, revealed the clipboards revealing patient information was an infringement on patient rights of confidentiality. Futher interview, confirmed the area where the clipboards were lying was a public corridor and visitors had access to those areas.

Interview on 02/02/12 at 3:20 PM, with RN #2, revealed she was assigned to the patient in room 131 on the clipboard and she was ultimately responsible for the clipboard and the protection of the patient's information. Further interview revealed she should not have left the clipboard turned over.

Interview on 02/02/12 at 3:25 PM, with RN #3, revealed she was assigned to the patient in room 133 on the clipboard and she should have made sure the information was not available for the general public to read. Further interview revealed, she thought the clipboard was turned over, but indicated the general public could have read the information about her patient. Continued interview confirmed, RN #3 was ultimately responsible for the whereabouts of the clipboard.

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Based on observation, interview, record review and the facility's policy review, it was determined the facility failed to prepare and administer medications based on acceptable standards of practice for one (1) of nineteen (19) patients (Patient #17) and two (2) unsampled patients. Medication was not administered correctly for a patient with a Gastrostomy tube and sliding scale insulin (SSI) was not administered as per Physician's orders.

The findings include:

1. Review of the facility's policy, Placement, Verification, and Maintenance of Nasogastric, Orogastric, and Duodenal Tubes in Adults, Policy #A08-110, dated 11/09, revealed procedures for administration of medication to include: item number five (5) to instruct staff to avoid combining multiple medications due to possible drug/drug interactions, and item number six (6) indicating to administer each drug separately.

Review of facility's guidelines for medication administration, taken from Mosby's Nursing Skills, 7th edition, 2010, revised January 2012, revealed item number twelve (12) to read, "check placement of feeding tube using an appropriate method, such as checking external tube length against last radiograph, checking for negative pressure during an attempt to withdraw fluid from the feeding tube, measuring the pH of aspirate contents, and observing for unexpected changes in residual volumes." Item number thirteen (13) states to check for gastric residual. Item fifteen (15) indicates to draw up thirty (30) milliliters (mL) of water in syringe. Item sixteen (16) indicates to flush the tube. Further review revealed, item number twenty (20) instructs to administer the medication by pouring into the syringe. Also, it states if administering more than one medication, give each separately, and flush between medications with fifteen (15) to thirty (30) mL of warm water. Lastly it states to follow the last dose of medication with thirty (30) to sixty (60) mL of warm water.

Observation, on 02/02/12 at 2:00 PM, of Registered Nurse (RN) #5 during a medication pass, revealed all medication was crushed together and then administered together. Further observation revealed, RN #5 did not check placement of the gastrostomy tube (GT) prior to the administration of medications.

Interview, on 02/02/12 at 2:30 PM with RN #5 revealed placement should have been checked prior to the administration of medication.

Observation, on 02/03/12 at 10:30 AM, of RN #6, performing her medication pass, revealed all medication was crushed together with the exception of the liquid medication to be administered. Further observation revealed, RN #6 flushed the GT but she did not verify placement prior to flushing. Continued observation revealed, RN #6 aspirated the medication into a piston syringe and pushed the medications into the GT and she continued to use this method of administration until all medications were administered.

Interview, on 02/03/12 at 11:00 AM, with RN #6, revealed she did not check placement prior to the administration of the medication. RN #6 verbalized, "the actual placement is within the stomach. I just look at the outside." Further interview revealed, she did not follow the facility's policy regarding appropriate placement verification of GT and the administration of medications.

Interview, on 02/03/12 at 11:30 AM, with RN #8, revealed she could not identify the last in-service on appropriate medication administration of GTs. Further interview revealed, she acknowledged the medication administration was not performed accurately and correctly per the facility's policy and standards of practice.

2. Record review for Patient #17 revealed an admission date of 05/23/11 and diagnoses which included Cholangitis (an infection of the common bile duct, the tube that carries bile from the liver to the gallbladder and intestines), Diabetes, and a history of Liver Transplant in 02/10. Further review of the record revealed the patient was NPO (nothing by mouth on 05/27/11).

Review of the Physician's Orders dated 05/24/11 for Regular Insulin to be administered every six (6) hours if NPO. This Insulin was on a sliding scale as follows:
2 units if FSBS (fingerstick blood sugar) was 150-199 mg/dl (milligrams per deciliter)
4 units if FSBS was 200-249 mg/dl
6 units if FSBS was 250-299 mg/dl
8 units if FSBS was 300-349 mg/dl
10 units if FSBS was 350-399 mg/dl
12 units if FSBS was greater than 400 mg/dl.

Review of Patient #17's FSBS on 05/27/11 revealed at 12:10 AM the patient's FSBS was 215 mg/dl, at 6:44 AM the FSBS was 207 mg/dl, at 12:24 PM the FSBS was 162, and at 9:16 PM the FSBS was 226 mg/dl.

Review of the Medication Administration Record (MAR) for 05/27/11 revealed no documented evidence the Regular Insulin was administered as ordered at 12:10 AM, 6:44 AM, 12:24 PM, and 9:16 PM.

Interview, on 02/02/12 at 2:58 PM, with the 8th Floor Patient Care Manager revealed the Regular Insulin should have been administered as ordered per the sliding scale.

Based on interview, record review, and the facility's policy review it was determined surgical counts were not documented as performed as per facility's policy for one (1) of nineteen (19) sampled patients (Patient #14).

The findings include:

Review of the facility's policy #A08-190, "Intraoperative Counts" revealed "Except in the case of an emergency, initial counts for sponges, sharps, and instruments shall be performed for all procedures performed in" the facility's Operating Rooms (OR). Further review revealed "subsequent counts shall be taken when...closure of a cavity within a cavity; at the closure of the peritoneum or first line of closure; during skin closure (immediately before completion of surgical procedure...".

Review of Patient #14's record revealed an admission date of 06/04/11 and diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed the patient was admitted for a lung transplant.

Review of the Operative Report dated 06/04/11 revealed Patient #14 was in the OR at 8:04 PM and received the lung transplant. Further review of the Operative Report revealed no documented evidence surgical counts for sponges, sharps, and instruments was performed during the closure of the cavity or the closure of the skin.

Interview, on 02/07/12 at approximately 3:00 PM, with OR Registered Nurses (RN) #1 and #2 revealed counts should be performed before surgery and after surgery as per the facility's policy as it was required.

Interview, on 02/02/12 at 2:25 PM, with the Associate Director of the Main ORs revealed the OR staff had indicated on 06/04/11 that they had performed the counts, however had failed to document the counts as per facility policy.