The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|JOHN C. LINCOLN NORTH MOUNTAIN HOSPITAL||250 EAST DUNLAP AVENUE PHOENIX, AZ 85020||Jan. 11, 2013|
|VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES||Tag No: A0122|
|Based on review of hospital policies/procedures, other documents, and interviews, it was determined that the hospital failed to adhere to their timeframe process for review of a grievance, and the provision of a response to 1 of 1 patients (Patient # 24), according to hospital policies.
The hospital policy titled Grievances, Patient #Q-303 (last reviewed 03/12), requires: "...2.2)...a 'patient grievance' is a written or verbal complaint...by a patient, or the patient's representative, regarding the patient's care...issues related to the hospital's compliance with the CMS Hospital Conditions of Participation(CoP)...(2.2.2) If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further action for resolution, then the complaint is a grievance...(2.4.1)The Network will attempt to resolve all grievances...with a goal of 7 business days from date of receipt...(2.4.2) If the grievance will not be resolved, or if the investigation will not be completed within 7 days, the Network will inform the patient or the patient's representative...of the 7 day goal, of the potential for a longer response time, and that a written response will be sent...(2.5.2) A written response of the investigation, findings, and actions will be sent to the complainant...."
The facility provided the surveyor a copy of a written complaint submitted to the facility by the patient and family, dated November 25, 2012 with multiple allegations regarding patient care issues.
Employee # 1 confirmed in an interview conducted on 1/9/13, no written response had been sent to date, and the facility did not follow their policy and procedure.
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based on review of hospital policies/procedures, medical records, documents, and interviews, it was determined that the hospital failed to implement their process for investigating, documenting and resolving 1 of 1 patient's allegations of abuse (Patient #5), according to hospital policies.
The hospital policy titled Grievances, Patient #Q-303 (last reviewed 03/12), requires: "...(2.2.2) If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further action for resolution, then the complaint is a grievance...(2.2.5) Patient complaints that become grievances also include...an allegation of abuse...(2.2.6) All verbal or written complaints regarding abuse...are to be considered a grievance...(2.4.1) The Network will attempt to resolve all grievances...with a goal of 7 business days from date of receipt....(2.4.2) If the grievance will not be resolved, or if the investigation will not be completed within 7 days, the Network will inform the patient...of the 7 day goal, of the potential for a longer response time, and that a written response will be sent...(2.5.2) A written response of the investigation, findings, and actions will be sent to the complainant...."
The hospital policy document titled Patients' Rights and Responsibilities requires: "...The right to be cared for in a safe setting free from abuse and harassment...your complaints will be investigated promptly and you will receive a response...."
The hospital's internal complaint investigation (occurrence report) included documentation of Patient #5's allegations of staff abuse that occurred on 11/16/12.
Risk Management Consultants #14 and #20, the Chief Nursing Officer (CNO), and the Director of Quality Management indicated during interviews conducted on 01/10/13 and 01/11/13, that the alleged event was reported to Adult Protective Services (APS) and verified that no further hospital follow up with the patient was provided or required.
There was no documentation that the patient was provided a written response of the investigation, findings, and actions per policy requirement, as of 01/11/13.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on review of policies and procedures, medical record and staff interview it was determined the nursing staff failed to evaluate the nursing care for 1 of 1 patient, (Patient # 24) as evidenced by:
1. failing to require nurses assess patients' bowel and bladder needs;
2. failing to require nurses assess the patients' ability to feed self; and
3. failing to require nurses assess the patient is receiving the correct diet.
1. The hospital policy and procedure titled Bowel Care of Choice and Antacid of Choice Protocol requires: "...to provide guideline for providing medications for the relief of constipation...the physician or other licensed provider may order Bowel Care of Choice (BCOC)...to relieve constipation...assess patient complaint...assess bowel sounds...."
The hospital policy and procedure titled Urinary Retention Management Protocol requires: "...to provide guidelines for the management of patients with urinary retention...use the bladder scanner to confirm urinary retention in the following situations...post void residual...the patient is symptomatic and unable to void...frequent voiding < 100 cc per void...assess voiding patterns...."
Patient # 24 was admitted for Cervical Stenosis and underwent a Posterior Cervical C3 C6 Decompression Laminectomy on 6/19/12, according to the medical record. The patient was admitted to the Intensive Care Unit (ICU) from the recovery room. Documentation revealed the following:
The patient had a bladder scanner test done on 6/19/12 at 1745 hours. The bladder scan results showed the patient still retained 475 cc of urine in his bladder, after voiding 100 cc's of urine two times, and being incontinent once. On 6/19/12 at 2100 hours, the nurse documented that the patient voided small amounts of urine. On 6/20/12 at 0300 hours, the patient voided 100 cc's of urine. On 6/21/12 at 1830 hours and 2150 hours, the patient was incontinent of urine twice in bed. On 6/22/12 at 1630 the patient was incontinent in his briefs.
Daily urine output totals, and bowel movement documentation was documented on the form titled Graphic Chart Intake and Output every 24 hour period as evidenced below:
6/19/12 Intake 1743 cc, Output 730 cc plus incontinence; No Bowel Movement
6/20/12 Intake 2478 cc, Output 775 cc; No Bowel Movement
6/21/12 Incontinence 4 times; No Bowel Movement
6/22/12 Incontinence 6 times; No Bowel Movement
The Medication Administration Record revealed nursing documentation was blank under the order "Bowel Care of Choice," for bowel management.
The facility failed to follow its policies and procedures to manage bowel care and urinary retention. The nursing staff failed to activate the physician order for Bowel care of Choice.
Employee # 82 confirmed in an interview conducted 1/11/13 at 1112 hours, the nursing staff failed to follow hospital policies for urine and bowel problems, and activate the physician order for bowel care.
2. The hospital policy and procedure titled Clinical Nutrition Services # 1207 requires: "...to describe consults/ diagnoses which trigger nutrition assessments and care planning...early systematic nutrition assessments of in-patients is crucial to identify those at nutrition risk...consults may be initiated by any caregiver...."
Patient # 24 was admitted to the facility on on two separate admissions, 6/19/12 for Cervical Stenosis/Cervical Laminectomy and 7/3/12 for Urinary Track Infection, Right Lower Lobe Pneumonia and Hypotension. Documentation revealed the following:
The patient had a known poor appetite prior to this admission. On 6/21/12, the patient complained he was unable to swallow. The form titled Intake and Output demonstrated the percentage of food the patient consumed each meal:
6/19/12 No documentation for breakfast, lunch or dinner
6/20/12 50 % breakfast and 10% lunch, no documentation for dinner
6/21/12 90 % breakfast and 10 % lunch, no documentation for dinner
6/22/12 25 % breakfast, 0 % lunch and dinner
6/23/12 no documentation all three meals
Documentation in the medical record of July 3, 2012, revealed the patient was admitted to this facility from a residential facility. Staff from the residential facility documentation the form titled Resident Transfer Form, the patient needed total assistance with feeding. Nursing staff identified on the form titled Admission Database the patient had a poor appetite. Nursing staff documented on the form titled Patient Progress Note the patient needed applesauce to take his pills. Documentation on the form titled Intake and Output revealed the percentage of meal consumption taken in by the patient each day as evidenced below:
7/3/12 No documentation all three meals
7/4/12 No documentation all three meals except sleepy at lunch
7/5/12 10 % breakfast, refused lunch and dinner
7/6/12 30 % breakfast, 40 % lunch, no documentation for dinner
7/7/12 30 % breakfast, 40 % lunch, no documentation for dinner
7/8/12 No documentation breakfast and lunch, 30 % for dinner
7/9/12 75 % breakfast, no documentation lunch or dinner.
Nursing staff did not document in their daily progress notes, assessments of the patients ability to feed himself. The patients' poor food consumption did not alert staff to trigger a nutritional assessment. The facility failed to follow its policy and procedure for nutritional assessment.
Employee # 82 confirmed in an interview conducted 1/11/13 at 1112 hours, the nursing staff failed to assess the patient's ability to feed himself.
3 .Documentation in the medical record for Patient # 24, on 7/3/12, revealed the form titled Resident Transfer Form. The form accompanied the patient on admission to this facility from his residential facility. Documentation on the form identified the patient had been on a Puree- Thin Liquid diet, prior to admission to this facility. In the emergency room , the admitting doctor ordered a 2 gram sodium, low fat, low cholesterol diet. The admitting nurse documented on the Patient Admission Database, the patient was on a regular diet.
The nurse failed to assess the patient for the correct diet needed.
Employee # 82 confirmed in an interview conducted 1/11/13 at 1112 hours, the patient was not assessed for the correct diet.