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.


Based on patient and staff interview, record review, and review of the Hospial "Appropriateness of Examination Policy", nursing failed to supervise the care of a patient related to not notifying the physician of unperformed radiology orders for 1 of 7 patients sampled for nursing services (patient #5).

Findings include:

Patient #5 was interviewed on 3/27/2017 at 3:22 PM. The patient stated she had been at the facility for 5 days for a diabetic ulcer to her left great toe. She stated she had concerns of a radiology test not being done. She indicated she was supposed to have a scan to determine if she had osteo[DIAGNOSES REDACTED] and if so, she was to have her toe or part of her foot amputated. (According to Medscape, osteo[DIAGNOSES REDACTED] is an inflammation of the bone caused by an infecting organism). She confirmed she had been asking her nursing staff daily about when she would go for the test but they were not providing any information to her.

The patient's medical record was reviewed and revealed an admitting diagnosis for left great toe diabetic ulcer. The history and physical dated 3/21/2017, completed by the admitting medical doctor (MD) L, revealed a plan to rule out osteo[DIAGNOSES REDACTED]. A podiatry consult was ordered upon admission and MD K was assigned the patient. On 3/22/2017, MD K saw the patient and wrote a consult report stating a recommendation for a Ceretec scan to assess for osteo[DIAGNOSES REDACTED]. (A Ceretec scan is a nuclear test that uses a radioactive material to seek out areas of infection or inflammation in the body. The test is useful to determine if a patient has osteo[DIAGNOSES REDACTED].) Further, MD K recommended continued medical management until osteo[DIAGNOSES REDACTED] could be ruled out. A written order dated 3/22/2017 by MD K for a Ceretec scan was reviewed.
An interview was conducted with Registered Nurse (RN) A on 3/27/2017 at 3:30 PM. RN A stated she wasn't aware the patient was supposed to be having any tests. She reviewed orders within the electronic medical record and stated a nuclear medicine scan had been cancelled but she didn't know why. She then called nuclear medicine for clarification. Staff B, a nuclear medicine technician responded to the unit on 3/27/2017 at 4:05 PM. He stated he was aware MD K ordered the Ceretec scan but while trying to obtain more information about the patient, the nurse informed him the patient had an incision and drainage procedure to the left great toe. He told her that because the patient had surgery, the procedure would not be able to be performed and instructed her to notify the MD for alternate imaging. He stated the nurse returned his call and asked to order a 3-phase bone scan. He stated he told her the test was essentially the same as the Ceretec scan and would not be useful in this case. He explained, "The test works by the radioactive tracer going to an area with white blood cells. When you have surgery, the area has a lot of white blood cells and would cause white out conditions to where you couldn't see if the patient had osteo[DIAGNOSES REDACTED]." He stated he didn't receive any more information from nursing staff.

Both MD J and MD K's daily consultation notes were reviewed. On 3/23/2017, MD J noted a plan stating, "She has been seen by the podiatrist. He has ordered 3-phase bone scan. Depending on the results, she may need to have debridement and possibly even some removal of the toe." On 3/24/2017, MD J noted, "Podiatrist has come by and recommended nuclear medicine scan which probably will not be able to be done until Monday." On 3/25/2017, MD K noted, "She has not received her Ceretec scan due to processing delay. We are awaiting Ceretec scan. In the event that we have osteo[DIAGNOSES REDACTED], I recommend amputation of the hallux versus nonbone involving soft tissue infection would resolve with the recommendation of 2 weeks of continued IV (intravenous) antibiotics and wound care." (The hallux is the great toe.) On 3/25/2017, MD J noted, "Podiatrist has come by and we are waiting 3-phase bone scan to see if she does have osteo[DIAGNOSES REDACTED]." On 3/26/2017, MD J noted, "We are awaiting a 3-phase bone scan to be done on Monday to see if she has osteo[DIAGNOSES REDACTED]."

The printed and electronic medical record was reviewed. There were no notes anywhere within the record to indicate the physician was ever notified by nursing that the test was not able to be performed. A written policy titled "Appropriateness of Examination Policy" dated 8/13/2014 with a revision date 2/1/2017 was reviewed. It stated, "For inpatients, if the clinical diagnosis is [DIAGNOSES REDACTED]" A second written policy titled "Physician Notification of Patient Condition" dated 3/1/1998 with a revision date of 8/1/2015 was reviewed. It stated the objective was "to assure that patient's medical needs are met. When a patient's condition warrants the physician to be notified, the RN/LPN (licensed practical nurse) will notify the attending physician. Time and notification of information imparted will be recorded in the nursing notes.

An interview was conducted with the Risk Manager on 3/28/2017 at 08:55AM. She stated, "There was just a breakdown in communication." She stated the charge nurse should have contacted the physician and notified him the radiology test wasn't able to be performed. She confirmed the patient had waited four days to have the test. She further provided a progress note dated 3/28/2017 that stated, "Called MD K last night at approximately 5 PM regarding Ceretec test ordered for patient. Return call received at 7 PM. Discussed order for Ceretec and radiologist concerns regarding reliability of results. MD K was not aware of radiologist concerns. MD K stated test is appropriate to determine if patient has osteo[DIAGNOSES REDACTED] as it does not "light up" soft tissue, only white blood cells in bone and would like test done. Call placed to Radiology Director. Informed her of MD K's opinion of test and order to complete as ordered." The Risk Manager stated the patient would be receiving the test today and was currently being prepped for the procedure.

Based on patient and staff interview, and review of sample patient medical records and review of the Hospital Policy and Procedures for Complaints/Grievances, the facility failed to follow their own policy for reporting and resolving grievances for 2 of 7 sampled patients (sample patient numbers #2 and #3).

The findings are:

An interview was conducted with the Director of Nursing (DON) on 3/27/17 at approximately 2:25 PM. The DON stated that he did not recall immediately (the content of conversation with representative of patient #2). He stated he would consult his "notes" and return to continue the interview. After returning he stated he got a call from the wife of patient #2, who felt the room wasn't clean, and there could have been quicker response to caring for her husband. The DON stated he followed up to reiterate with all staff the need to be diligent with provision of care. He stated that environmental rounds are done to identify maintenance needs and housekeeping needs. He continued to state that the representative of patient #2 had stated they gave her husband's medications to the wrong patient, but she did not identify who the other patient was.

On 3/27/17 at approximately 2:45 PM an interview was conducted with unit manager (staff sample "P"). Staff "P" stated the wife of patient #2 had complained that her husband was not having his blood glucose (BG) checked at all, and he had been administered D-50 (a dextrose medication used to treat [DIAGNOSES REDACTED]). Staff "P" stated that the charge nurse (staff "Q") took care of the hypoglycemic episode. The unit manager stated the wife of patient #2 also complained that her husbands medications were given to his roommate. The unit manager (staff "P") stated that the roomate was actually given his own dose of the medication lisinopril (a blood pressure medication), and not the medication of patient #2.

An interview was conducted with the Risk Manager (RM) on 3/27/17 at approximately 10:50 AM. The RM stated that the only contact she had with the wife of patient #2 was when she called and reported that her husband fell on [DATE] at the physicians office building (not hospital property) This phone call was made on 2/28/17. He was at the building to see another physician who is not affiliated with the hospital. She was advised to contact the building manager for that building.

The RM was again interviewed on 3/27/17 at approximately 2:55 PM. She stated that the complaint of care voiced by the representative of patient #2 to the DON was not put into the complaint log and that it would be addressed. She further stated that the DON is new to the facility (and from out of state) and is not completely aware of all hospital practices.

The RM was again interviewed on 3/28/17 at approximately 11:00 AM. The RM confirmed that the hospital had received a letter written by the grandmother of sample patient #3. The RM confirmed that there was not a grievance placed in the grievance log based upon this letter. The letter was received in the mail room and date stamped 3/10/17. The date on the handwritten letter from the grandmother was 3/7/17. The letter was received in the inbox of the RM on 3/21/17. A letter was drafted dated 3/22/17, as a response to the grandmother. As of 3/28/17, there was still discussion about the content of the reply due to privacy concerns. The response addressed that the patient was screened to determine whether she qualified for various assistance programs, including the hospital's own charitable assistance program, and cites privacy concerns for being unable to provide many details due to patient privacy issues. The RM stated the hospital policy for resolving grievances was 7 days. (copy of the policy was provided).

The Hospital written policy for "Patient Complaint/Grievance Process", effective date 1/1/2004 and revised 5/21/2015 was provided for review. The policy defines the difference between complaints and grievances, and (in part) the process for addressing grievances as follows:

1.1 Patient Complaint: A written or verbal complaint is filed by a patient, or on a patient's behalf, and is resolved promptly by the staff present or available.
1.2 Patient Grievance: A written or verbal complaint that is filed by a patient, or on a patient's behalf, when a patient issue cannot be resolved by the staff present or available.
3.2 Complaints or grievances may be in written or verbal form.
3.4 The Quality Management Department ensures the patient is provided written notice of the decision regarding a complaint/grievance within 7 days of the hospital's receipt of the grievance.
4.2.6 The person documenting receipt of the complaint/grievance describes/summarizes the complaint in the patient/patient representative's words as best as possible, places the date, the time, and the signature of the person completing the report as indicated. The complaint is forwarded to the Risk Manager and/or Chief Quality Officer for follow up.
4.2.9 The report ultimately resides with the Risk Manager and Chief Quality Officer who ensures documentation of the complaint/grievance in the Hospital complaint/grievance log.
The Hospital complaint/grievance log was provided for review. The grievances presented by the representatives of sample patient #2, and sample patient #3 were not found in the complaint/grievance log.