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.
|ADVENTHEALTH WATERMAN||1000 WATERMAN WAY TAVARES, FL 32778||June 2, 2017|
|VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES||Tag No: A0122|
|Based on record review and interview, the facility failed to follow their own policies and procedures to review, investigate, and resolve patient grievances within a reasonable time frame for 1 of 2 (Patient #1) patients' grievances.
1. Review of the Patient Rights and Responsibilities policy and procedure revealed it became effective 9/1993 and was last reviewed on 10/2016. Further review of this policy and procedure revealed the following:
Grievance: A Grievance: A patient grievance is a formal written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care, abuse or neglect.
Staff present, who initially receive the concern or complaint, shall attempt to resolve the issue immediately. "Staff Present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient's complaint. However, if the complaint is a serious quality of care or legal concern, staff should enter event to the Risk Manager.
Risk management will determine if it is a complaint or grievance and refer to the appropriate department as necessary and, if appropriate, a letter of acknowledgement will be sent to the patient/representative within 5 days, unless the issue can be resolved immediately. A grievance log will be maintained to track status of grievances.
Turnaround time for review of the complaint and feedback to Risk Management by departments is 5 business days.
Risk management will collaborate with department manager(s) and send a letter, if appropriate, to the author of the grievance within 45 days of original complaint. Resolution will be documented in RiskMaster.
2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was not a filed complaint from Patient #1's family member regarding the failure to provide nutrition and of medication administered that caused excessive bleeding.
3. Interview on 6/1/2017 at 7:00 PM with the complainant revealed that she had complained to nursing staff of her father having received excessive amount of units of blood due to the physician completing cardiac surgery, when he was being administered Plavix 75 mg every day. The complainant further stated that she had visited Patient #1 at this facility and found that the family member had not been able to eat foods from 11/4/2016 to 11/19/201, and that she asked for Patient #1 to be placed on Total Parenteral Nutrition (TPN) for any meals. She also stated, Patient #1 was bleeding from his rectum and and his stomach where the Gastrostomy Tube was placed. All these concerns, she said, she brought to nursing staff's attention, and was told someone from administration would speak to her, but they did not.
4. Interview with the House Supervisor, RN, Staff #C on 6/2/2017 at 3:00 PM, revealed that she had met with the daughter of Patient #1, who had complained for her father, and stated to this surveyor "I did do a incident form on 12/6/2016, about Patient #1's daughter's complaint of the bleeding, upset about the Plavix medication administered, and the delay of administering TPN to meet his nutritional needs."
5. Interview on 6/1/2017 at 2:30 PM with the Director of Risk Management revealed that they were unable to locate a complaint/grievance form written regarding Patient #1, but did find an incident report from Staff #C, but it had not been acted upon, or investigated. Also there was not a grievance documented with a resolution or neither was it in the grievance log.
6. Further interview on 6/1/2017 at 3:00 PM with the Risk Manager revealed that they have not investigated a grievance voiced by Patient #1's daughter.
|VIOLATION: AUTOPSIES||Tag No: A0364|
|Based on medical record review, review of Policy and and Procedures, and interview, the facility failed to honor a request for an autopsy for 1 of 10 patients reviewed (Patient #1).
1. An Interview on 6/1/2017 at 7:00 PM with the daughter of Patient #1 revealed she stated, "I requested an autopsy, and the only thing the nurses asked me was what funeral home did I want to send my father. I felt that since in my father's case of medical errors, which it was an unusual death, and I wanted an autopsy. I asked Registered Nurse (RN), Staff #A at the time of my father's death for an autopsy, but nothing was done. I was referred to the House Supervisor, RN, Staff #D, and told her I wanted an autopsy and she said that the hospital does not do that, the physician has to order the autopsy and that it cost $3000.00. I called the Medical Examiner (ME) and gave them my dad's name and they said that the death is usually reported to them right away, but it had not been reported. They said the hospital not reporting the death to them is odd, and that they would perform the autopsy for me for free. The ME did an autopsy for me for which I and the hospital was provided with a copy."
During an interview on 6/2/2017 at 2:45 PM with RN, Staff #A, she stated, "The daughter of Patient #1 requested an autopsy of her father's death, but I did not inform the physician, have her sign a consent form, but referred her to my house supervisor, Staff #D."
During an interview on 6/2/2017 at 3:15 PM with RN, Staff #D, when she was asked if an autopsy was requested by the family, she stated, "yes, the daughter of Patient #1 after his death on 12/7/2016 requested an autopsy and I explained to her that a physician has to order an autopsy, and it costs $3000.00." When RN, Staff #D, was asked if she informed the physician of the daughter's request or provide her a consent for autopsy, she stated, "No."
During an interview on 6/2/2017 at 4:00 PM with the Critical Care physician, he stated, "I would always recommend an autopsy."
2. Review of Patient #1's medical record showed at the time of death on 12/7/2016 at 3:56 PM, RN, Staff #A, documented the daughter was in Patient #1's room at time death.
Autopsy Grid. Autopsy Requested. Yes. Daughter requested Autopsy on her departure at 4:30 PM.
The "Authorization for Post Mortem Examination and Removal and Retention of Organs" form for consent of autopsy was not in this medical record.
3. Review of the facility's Policy and Procedures titled Death, Report of/Post Mortem/Autopsy/Morgue which was revised on 9/2015 revealed the following:
deceased Person; A patient who has ceased to have respiratory, cardiac, and neurological functions as determined by the physician or qualified designee.
Autopsy consent will be obtained after the physician, house supervisor or Charge Nurse discuss the autopsy procedure with the family. The "Authorization for Post Mortem Examination and Removal and Retention of Organs" form shall be use to obtain consent.
Physician Ordered Autopsy
Pathology will bill Florida Hospital Waterman
Next of kin ordered autopsy: The next of kin is responsible for all charges, including the pathologist fee. This person should be referred directly to the pathology billing office during regular business hours.
A diagnosis is not known with reasonable certainty
To allay concerns, and/or provide reassurance to the family or public regarding the death
House Supervisor/Designee Role;
Once the consent for autopsy has been obtained, the house supervisor is responsible to notify the pathologist of the pending autopsy. The pathologist may refer the autopsy to the Medical Examiner. The patient's medical record, autopsy consent form accompanies the patient.