HospitalInspections.org

Based on record review and interview the hospital failed to ensure the Grievance Policy was followed as evidenced by 2 of 2 Grievances reviewed having no documented evidence of a written response being sent to the complainant. Findings:

Review of a Grievance Report filed 09/08/10 revealed the complainant for patient #4 had filed a grievance in regards to the Emergency Room visit on 09/08/10. Further review revealed no response letter to the complainant.

Review of a hospital policy titled "Grievance Policy", date issued March 2000, last reviewed 11/24/09, presented as current hospital policy at the time of this Grievance Report read in part: "...IV. Procedure...the hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on the behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

In an interview on 08/02/11 at 2:30 p.m. with S4RN, PI/Risk Management she stated she is the person responsible for grievance response. S4RN confirmed there was no written response per hospital policy to the grievance filed by the complainant of patient for the 09/08/10 ER visit.

In an interview on 08/02/11 with S2DON she confirmed there was no written response per hospital policy to the grievance filed by the complainant of patient for the 09/08/10 ER visit.

Review of a Grievance Report filed 06/08/11 revealed the complainant for patient #4 had filed a grievance in regards to the Emergency Room visit on 06/08/11. Further review revealed no response letter to the complainant.

Review of a hospital policy titled "Complaint/Grievance Policy", date issued March 2000, last reviewed 3/2011, last revised 5/2011, presented as current hospital policy at the time of this Grievance Report read in part: "...III. Procedure...G. Grievances are considered completed when an approved response has been mailed to the patient/complainant...H. All persons with a grievance will receive a written notice of the investigators review within 30 working days."

In an interview on 08/02/11 at 2:30 p.m. with S4RN, PI/Risk Management she stated she is the person responsible for grievance response. S4RN confirmed there was no written response per hospital policy to the grievance filed by the complainant of patient for the 06/08/11 ER visit.

In an interview on 08/02/11 with S2DON she confirmed there was no written response per hospital policy to the grievance filed by the complainant of patient for the 06/08/11 ER visit.

Based on record review the hospital failed to ensure the patient/patient's representative received informed consent prior to treatment as evidenced by a physician removing an impaled object from under the scalp of a patient when there was no documented consent for treatment signed. Findings:

Review of the documentation kept by the patient check in clerk (referred to as the PBX operator by the hospital) revealed patient #4 presented to the Emergency Room (ER) at 5:21 p.m. on 06/08/11. According to the complainant patient #4 was taken to the hospital by car with the Father and a female family friend. The complainant followed in a separate vehicle and arrived at Abbeville General Hospital approximately 8 minutes after patient #4. The complainant stated the stick was already removed from the child's head by "a doctor in the hall."

In a telephone interview on 08/02/11 at 3:15 p.m. with S3MD he stated that he was near the ER and was approached by the Father of patient #4 who was carrying the child. S3MD reported the child's Father was hysterical and said "do something quick, something is wrong." S3MD stated he advised the Father to see the ER physician to which the Father replied "are you crazy, this could be in his brain." S3MD stated he again advised the Father to see the ER physician and gave the Father a piece of gauze he grabbed from the nearby laboratory. S3MD stated "the Father had a valid point, all were hysterical, and he was now concerned that the hysterical Father could cause further injury if he bumped the stick on something as he was carrying the child around." S3MD further stated that based upon his experience he was confident the stick was under the scalp and not in the cranial vault. S3MD stated the stick was in an anterior to posterior line on the side of the head of patient #4, but could not remember which side. S3MD stated he pulled the stick out of the scalp of patient #4 in the lobby of the ER to prevent the Father from causing further damage and again advised that the patient be seen in the ER.

Further review of the documentation by the PBX operator revealed the patient was called (by a number assigned when he presented at 5:21 p.m.) at 5:55 p.m. for triage. The documentation indicates the patient had "left."

In an interview on 08/03/11 at 9:25 a.m. with S8RN he stated that patient #4 was gone when he called him for triage. He further stated he saw the child in the lobby prior to triage of the patient ahead of patient #4 and he did see the stick was in the head of patient #4. He further stated the child "appeared in no distress."

In an interview with S5RN, ER Director, he stated that since the child was never triaged there was no medical record and no consent form was filled out when the surgeon removed the stick from the head of patient #4.

Based on record review and interview the hospital failed to ensure Performance Indicators that were not meeting the hospital threshold were addressed as evidenced by no policy being developed and implemented for door to triage times and "Left Without Being Seen (LWBS)/Left Without Being Triaged (LWBT)." Findings:

Review of the Emergency Room Performance Improvement Monitor for 2011 revealed the LWBS rate of the hospital was identified and tracked for each month of 2011. Further review revealed the PI indicator was above 2% for each month from January through June. Documentation under a section titled "analyze" revealed "still attempting to reach 2% for LWBS." Review of documentation under "Improve" revealed "1. Continue to monitor and evaluate, 3rd qtr (quarter) with full implementation."

Review of an "Operational Assessment" conducted in April 2011 by the contracted ER Physicians group revealed that there was a need to "Improve Door to Provider (triage)" and "Decrease LWOT (left without triage.)"

In an interview on 08/03/11 at 10:43 a.m. with S5RN, ER Director, he stated that the hospital is working on plans to address door to triage times and LWBS/LWBT but the policies have not been submitted for approval.

Based on record review and interview the hospital failed to ensure there were adequate numbers of staff on duty in the Emergency Room as evidenced by 1) failing to fill the open 10a-10p triage shift on 06/08/10 causing delays in triage up to 1 hour and 21 minutes prior to the patient being seen by any hospital clinical staff and 2) failing to fill multiple open staffing positions for 9 of 14 sampled days. Findings:

1)

In an interview on 08/03/11 at 8:20 a.m. with S2DON she stated the Core Staffing for the ER is 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; and a Triage RN for the high volume period from 10 a.m. - 10 p.m.

In an interview on 08/03/11 at 9:25 a.m. with S8RN, ER, he stated that on 06/08/11 the ER did not have a staff member for the 10 a.m. - 10 p.m. Triage RN position. S8RN further stated they were short handed and very busy.

Review of the medical records of the 3 patients (#1, #2, #3) who checked in on 06/08/11 just prior to patient #4, the documented presentation time of patient #4 of 5:21 p.m. the documentation that he (#4) was not called until 5:55 p.m., and the 2 patients (#5, #6) who checked in just after patient #4 revealed 0 of 6 patients were triaged within the hospital guidelines of 5 minutes.

Review of a hospital Emergency Department policy titled "Advocate Area",date issued 05/24/93, last reviewed 03/05/08, presented as current hospital policy, reads in part: "...III. The patient will be greeted by the Advocate Nurse within five minutes upon arrival to reception area. 2. The Advocate Nurse will take vital signs, and document the patient's chief complaint..."

In an interview on 08/03/11 at 10:43 a.m. with S5RN, ER Director, he confirmed that 0 of 6 patients who checked in to the ER between 4:24 p.m. and 6:20 p.m. on 06/08/11 were triaged within the hospital guidelines of 5 minutes. S5RN, ER Director, further confirmed that the hospital has adopted the Triage RN position but has developed and implemented no policy regarding the hospitals expectation of presentation to triage time, so the current policy titled "Advocate Area" is the only policy that defines presentation to triage time.

In an interview on 08/03/11 at 10:43 a.m. with S2DON she confirmed that 0 of 6 patients who checked in to the ER between 4:24 p.m. and 6:20 p.m. on 06/08/11 were triaged within the hospital guidelines of 5 minutes.

2)

Review of the Nurse Staffing Sheets for 07/19/11 - 08/01/11 revealed the hospital's Emergency Room was short staffed on 9 of 14 days. (07/19/11, 07/20/11, 07/22/11, 07/23/11, 07/24/11, 07/26/11, 07/27/11, 07/28/11, and 08/01/11)

A focused review of 4 of the 9 when core staffing was not met revealed:

07/20/11

6 of 21 patient records revealed the patient was not triaged within the hospital guideline of 5 minutes. The longest presentation to triage was 28 minutes.

07/22/11

15 of 28 patient records revealed the patient was not triaged within the hospital guideline of 5 minutes. The longest presentation to triage was 25 minutes.

07/26/11

17 of 25 patient records revealed the patient was not triaged within the hospital guideline of 5 minutes. The longest presentation to triage was 1 hour and 9 minutes.

07/27/11

12 of 21 patient records revealed the patient was not triaged within the hospital guideline of 5 minutes. The longest presentation to triage was 1 hour and 5 minutes.

This was in addition to the 0 of 6 not triaged within the hospital guideline of 5 minutes on 06/08/11.

The failure rate to meet the presentation (door) to triage time of 5 minutes for 56 records reviewed was 62%.

In an interview on 08/03/11 at 8:20 a.m. this was confirmed by S2DON.

Based on record review the hospital failed to revise the policy and procedure for the Emergency Room as evidenced by a change in the Core Staffing pattern adopted by the hospital which includes policy and procedure for door to Triage times. Findings:


In an interview on 08/03/11 at 8:20 a.m. with S2DON she stated the Core Staffing for the ER is 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; and a Triage RN for the high volume period from 10 a.m. - 10 p.m.

Review of a hospital policy titled "Staffing Plan Emergency Services", accepted, reviewed and revised on 05/24/11 revealed an acuity grid for ER staffing. Further review revealed ER Staffing was 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; 2 RN's and 1 LPN for 7 a.m. - 7 p.m.; and a Triage RN for the high volume period from 10 a.m. - 10 p.m.

In an interview on 08/03/11 at 9:25 a.m. with S8RN, ER, he stated that on 06/08/11 the ER did not have a staff member for the 10 a.m. - 10 p.m. Triage RN position. S8RN further stated they were short handed and very busy.

Review of the medical records of the 3 patients (#1, #2, #3) who checked in on 06/08/11 just prior to patient #4, the documented presentation time of patient #4 of 5:21 p.m. the documentation that he (#4) was not called until 5:55 p.m., and the 2 patients (#5, #6) who checked in just after patient #4 revealed 0 of 6 patients were triaged within the hospital guidelines of 5 minutes.

Review of a hospital Emergency Department policy titled "Advocate Area", date issued 05/24/93, last reviewed 03/05/08, presented as current hospital policy, reads in part: "...III. The patient will be greeted by the Advocate Nurse within five minutes upon arrival to reception area. 2. The Advocate Nurse will take vital signs, and document the patient's chief complaint..."

In an interview on 08/03/11 at 10:43 a.m. with S5RN, ER Director, he confirmed that 0 of 6 patients who checked in to the ER between 4:24 p.m. and 6:20 p.m. on 06/08/11 were triaged within the hospital guidelines of 5 minutes. S5RN, ER Director, further confirmed that the hospital has adopted the Triage RN position but has developed and implemented no policy regarding the hospitals expectation of presentation to triage time, so the current policy titled "Advocate Area" is the only policy that defines presentation to triage time.

In an interview on 08/03/11 at 10:43 a.m. with S2DON she confirmed that 0 of 6 patients who checked in to the ER between 4:24 p.m. and 6:20 p.m. on 06/08/11 were triaged within the hospital guidelines of 5 minutes.

Based on record reviews (personnel files, job description, and "Orientation" policy) and staff interviews, the hospital failed to ensure the Emergency Room (ER) nurses were qualified and competent in emergency care as evidenced by failing to ensure the ER Director, S5RN (Registered Nurse), provided department specific orientation process as per policy for 1 of 2 ER RN's (S8RN) whose personnel records were reviewed. Findings:
Review of the personnel file revealed S8RN's date of hire was 07/25/05 and position was in the BHU (behavioral health unit). Further review revealed S8RN was transferred to the ER on 08/10/10. There was no documented evidence of S8RN's job description and/or department specific orientation for the ER since he began working in the department on 08/10/10, about a year ago.
In an interview conducted on 08/03/11 at 1:25pm and at 1:40pm, S5RN, ER Dir., indicated S8RN, ER, had been working in the ER for approximately one year (08/10/10). The ER Director further indicated all ER nurses go through a three (3) month orientation process. S5RN verified there was no documented evidence of a job description and/or department specific orientation for the ER in S8RN's personnel file. S5RN, ER Dir., did not know why there was no ER job description and/or department specific orientation competency evaluation performed for S8RN, ER, as per policy.
During an interview on 08/03/11 at 1:30pm, S2DON verified there was no documentation of a job description and/or department specific orientation for the ER in S8RN, ER, personnel file. The DON indicated all employees must have job descriptions as well as department specific orientation documentation in the personnel files as per policy. S2DON reported S5RN, ER Director is responsible to ensure the department specific orientation and job descriptions are completed and in the personnel files for all nurses in the ER as per policy. The DON denied knowledge why the policy for department specific orientation and a job description were not completed for S8RN, ER, by S5RN, ER Director. S2DON denied knowledge why S5RN, ER Director failed to follow the policy for department specific orientation and job description.
Review of the policy titled, "Management of Human Resources (HR)", Orientation, Training and Education of Staff, Date Issued on January of 1996, with no revised or reviewed date(s), presented as the hospital's current "Orientation, Training" policy for ER Registered Nurses on 8/3/11 at 2:10pm by S1CNO, indicated "Abbeville General Hospital recognizes the need for formal education. The education programs are developed to provide skills and knowledge to help us respond to the needs of those people who support the success of the organization. The objective is to provide competency-based orientation programs consistent with the individual needs and the role expectations of the hospital. The scope is hospital-wide orientation of new employees. The Education Coordinator directs the Education Department under the administrative review of the Director of Patient Care Services and works in close contact with the Director of Human Resources. This person is responsible for directing a hospital-wide orientation. General Orientation will be scheduled within the employee's first 30 days of employment. As needed, general nursing orientation is provided by the Education Department. Nursing Orientation is continued by the Department Leaders and is department specific. The Department Leaders are responsible for the implementation and documentation of department specific orientation and competency testing. Department Specific Orientation is coordinated by Department Leaders. This orientation is based on individual needs, assessment of skills, knowledge, and the state of competency. It includes department specific policies and procedures as well as standards relating to service or care provided and requirements by various regulatory agencies. The employee is provided with a job description. The Emergency unit employee will be provided additional education during departmental orientation. Department specific checklists will be completed within six month employee appraisal period and place in the employee's file in the department or designated location. A copy of this checklist must also be forwarded to Human Resources for placement in the employee's personnel file within six (6) months. All areas of orientation that have not been completed must be identified and a mechanism developed for obtaining and evaluating competency."



26458