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.

LAKE CUMBERLAND REGIONAL HOSPITAL 305 LANGDON STREET SOMERSET, KY 42503 April 6, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review it was determined the facility failed to ensure patient grievances were investigated timely and thoroughly, and a written response provided for one (1) of ten (10) sampled patients (Patient #1). On 02/24/17, Patient #1's family member voiced concerns to the Senior Director of Emergency Services during "senior rounding" regarding infection control issues in the Emergency Department (ED); failure to obtain a consultation with a cardiologist in a timely manner; a "rude" and "verbally abusive" nurse in the ED; failure to obtain laboratory studies (a follow-up troponin level) within the ordered timeframe; and the facility's refusal to transfer the patient, upon request, out of the ED. Further interviews revealed the Senior Director wrote down the concerns, took the telephone number, and informed Patient #1 he would follow up on their concerns and let them know the outcome. Patient #1 stated the facility had not had any contact with them regarding their grievances.

Refer to A0118.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review it was determined the facility failed to ensure patient grievances were investigated timely and thoroughly, and a written response provided for one (1) of ten (10) sampled patients (Patient #1). On 02/24/17, Patient #1's family member voiced a grievance to the Senior Director of Emergency Services during "Senior Rounding" regarding infection control issues in the Emergency Department (ED), failure to obtain a consultation with a cardiologist in a timely manner, a "rude" and "verbally abusive" nurse in the ED, inability to obtain laboratory studies (a follow-up troponin level) within the ordered timeframe, and a refusal to transfer Patient #1 to another facility from the ED. The Senior Director wrote down the concerns, took the family member's telephone number, and informed Patient #1 that he would follow up with their concerns and let them know the outcome. However, interview with Patient #1 revealed the facility had not contacted them regarding their grievances, thirty-nine (39) days after the grievance was lodged with the facility.

The findings include:

Review of the facility's policy for "Patient Complaint/Grievance Process," revised on 11/01/11, revealed at the time of registration all patients were informed of the hospital's internal grievance process using the Patient Admission pamphlet and Patient Rights were also posted in registration areas. The policy stated the Patient Admission Pamphlet included written directions on how to submit a compliment or complaint. According to the policy, any team member who received a verbal concern or complaint, regarding the patient care provided, an allegation of abuse or neglect, or failure of the hospital to comply with one or more Conditions of Participation or other Centers for Medicare & Medicaid Services (CMS) requirements, from a patient and/or their representative would attempt to resolve the complaint immediately. If unable to do so, the team member should request the presence of the Department Manager or House Supervisor and the Patient Representative and remain with the patient until the manager arrived. If unable to resolve, the patient should be informed and the complaint would then meet the definition of a grievance and should be forwarded immediately to the Quality Director for resolution or investigation and follow-up with the patient or their representative. The grievance, actions taken to resolve, and the patient's response would be documented on the Manager's Feedback Form and immediately forwarded to the Quality Director or designee within twenty-four (24) hours. If the investigation was not or would not be completed within seven (7) business days, the patient would be notified by phone call or mail that the facility was still working to resolve the grievance and that the facility would follow up with a written response within thirty (30) days.

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 02/22/17 through the ED with chest pain and the patient was diagnosed with unstable Angina. Patient #1 was admitted to the Telemetry Unit and followed by the facility's Hospitalist. The facility discharged Patient #1 home on 02/25/17.

Interview with Patient #1 and Patient #1's family member on 04/04/17 at 10:05 AM revealed Patient #1 went to the ED because of chest pain. The facility diagnosed Patient #1 with unstable Angina and admitted the patient to the Telemetry Unit of the facility. Continued interview revealed on 02/24/17 the Senior Director of Emergency Services came to Patient #1's room and asked how "everything" was. Patient #1's family member stated she lodged numerous complaints with the Senior Director including infection control issues in the Emergency Department (ED), failure to obtain a consultation with a cardiologist for Patient #1 in a timely manner, a nurse in the ED being "rude" and "verbally abusive," failure to obtain laboratory studies (a follow-up troponin level) within the physician ordered timeframe, and the facility's refusal to transfer the patient at the patient and family's request to another facility from the ED. Further interview revealed the Senior Director wrote down the concerns, took the telephone number of Patient #1's family, and informed Patient #1 that he would follow up with their concerns and let them know the outcome. Patient #1 stated as of that day (39 days after the grievance was lodged) the facility had not contacted them regarding their grievances.

Review of the Facility's Grievance Log dated February 2017 revealed only one (1) patient had lodged a grievance for the entire month; however, there was no evidence on the Grievance Log that Patient #1 or his/her family had filed a grievance with the facility.

Review of the "Senior Rounding Sheet" dated 02/24/17 revealed the Senior Director of Emergency Services documented Patient #1's family member's concerns. The Senior Director documented, "ED was dirty, stretcher was dirty, corners of the ED rooms were dirty and there was blood on the floor." Continued review of the rounding sheet revealed the Senior Director documented that Registered Nurse (RN) #1 was "snippy" and because there was no bed at Facility #2, RN #1 "was going to make [Patient #1] sign out Against Medical Advice (AMA) and go to [Facility #3] in their POV [personally owned vehicle]." Further review of the rounding sheet revealed the Senior Director had also documented that the facility was "late consulting [Physician #3], and the facility was late obtaining" the patient's last troponin level and the patient was told it was because the phlebotomist "messed it up in the ED." In addition, the Senior Director documented the phone number for Patient #1's family member on the Rounding Sheet.

Interview with Registered Nurse (RN) #1 on 04/04/17 at 10:54 AM revealed she recalled working with Patient #1 and Patient #1's family member. RN #1 stated that Patient #1's family member was very upset because a cardiac consultation was not performed on 02/22/17. Continued interview with RN #1 revealed that she also recalled Patient #1's family member becoming upset because the lab technician was late coming to the floor to obtain a blood draw for the patient's troponin level. RN #1 stated she informed the Unit Manager of the patient's concerns.

Interview with the Unit Manager on 04/04/17 at 10:35 AM revealed nursing staff informed him that Patient #1's family had concerns regarding a cardiac consultation. He stated he spoke with Physician #3, the cardiologist, and the cardiologist evaluated Patient #1 on 02/23/17. Continued interview with the Unit Manager revealed that he did not enter this complaint into the system because he felt like it had been resolved. The Unit Manager stated he was unaware of any other concerns regarding Patient #1's care.

Interview with the Senior Director of Emergency Services on 04/04/17 at 11:05 AM revealed he conducted a "senior management round" on 02/24/17 and spoke with Patient #1's family member. The Senior Director stated that he recalled Patient #1's family member being upset that their private physician was not seeing patients anymore at the facility. The Senior Director also stated that he could not do anything about that issue and felt it was resolved. Further interview revealed that he took Patient #1's family member's complaints regarding the ED being dirty seriously and spoke with the ED Manager and Environmental Services Manager regarding those issues. The Senior Director stated he also took the allegations regarding RN #1 seriously, but knew that she had already resigned and felt that issue was resolved. Continued interview revealed that he "thought" the issue with failure to appropriately transfer Patient #1 out of the ED at the patient's request was resolved because Patient #1 agreed to be admitted to the facility. The Senior Director stated that he had not followed up with the Lab nor had he discussed any of the concerns of Patient #1's family member with the Risk Manager or Quality Manager.

Interview with the Risk Manager on 04/03/17 at 1:05 PM revealed she was never informed of Patient #1 and Patient #1's family member's grievances. The Risk Manager stated that all complaints that could not be resolved at the patient's bedside should be entered into the system and her department investigated and followed up with the patient. Continued interview revealed that Patient #1's complaints should have been entered into the system and follow-up should have taken place per facility policy.
VIOLATION: EMERGENCY LABORATORY SERVICES Tag No: A0583
Based on interviews, record reviews, and review of facility policy it was determined the facility failed to have laboratory services available to ensure acute myocardial infarction (AMI) profiles were conducted in a timely manner for three (3) of ten (10) sampled records reviewed (Patients #1, #3, and #4).

The findings include:

Review of the facility's policy titled "Laboratory/Nursing Information," revised 01/13/17, revealed that timed or urgent tests must be collected at a specific time, to ensure appropriate patient treatment. According to the policy, this included such tests as therapeutic drug monitoring, post-transfusion hematocrit testing, or acute myocardial infarction (AMI) profile. The policy stated timed blood samples would be collected within a one-hour window (30 minutes before or 30 minutes after the given time for the test.)

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 02/22/17 through the Emergency Department (ED) with complaints of chest pain and was diagnosed with unstable Angina. Patient #1 was admitted to the Telemetry Unit and followed by the facility Hospitalist. Continued review of the medical record revealed that an initial AMI profile was drawn on 02/22/17 at 10:15 AM with an order for a repeat level to be conducted three (3) hours from the initial draw (which would have been 1:30 PM), and another repeat level six hours from the initial draw (which would have been at 4:30 PM.) Further review of the record revealed the AMI profile was drawn at 10:15 AM, 1:30 PM, and 5:23 PM (one hour later than ordered.) Interview with Patient #1 and Patient #1's family member on 04/04/17 at 10:05 AM revealed at approximately 5:30 PM on 02/22/17, when the facility did not conduct the 4:30 PM test, they asked staff why it had not been done, which prompted staff to conduct the test.

Review of the medical record for Patient #3 revealed the facility admitted Patient #3 on 03/30/17 to the Telemetry Unit from the ED with diagnoses that included Heart Failure, Hypertension, Chronic Pain, and Anxiety. The facility conducted an initial AMI profile for Patient #3 on 03/30/17 at 9:15 PM, with an order for a repeat level to be conducted three (3) hours from the initial draw (which would have been 12:15 AM), then six hours from the initial draw (which would have been at 3:15 AM). Further review of the record revealed an AMI profile was conducted for Patient #3 at 9:15 PM, 12:36 AM, and 4:05 AM (50 minutes later than ordered).

Review of the medical record for Patient #4 revealed the facility admitted Patient #4 on 02/22/17 to the Telemetry Unit from the ED with diagnoses that included Syncope, COPD, and Dehydration. Patient #4 was admitted to the Telemetry Unit and followed by the facility's Hospitalist. An initial AMI profile was drawn for Patient #4 on 02/22/17 at 8:01 PM, with an order for a repeat level to be conducted three (3) hours from the initial draw (which would have been at 11:01 PM). Further review of the record revealed the AMI profile was drawn at 8:01 PM and 12:00 AM (one hour later than ordered).

Interview with the Unit Manager of the Telemetry Unit on 04/04/17 at 10:35 AM revealed nursing staff could see physician orders on each chart; however, there was no way for them to track when laboratory studies were due for the patients on the unit.

Interview with the Laboratory Manager on 04/04/17 at 10:18 AM revealed that all timed orders should be performed within 30 minutes of the time for the test. Further interview revealed that she had no ability to track when orders were completed to ensure they were conducted within the ordered timeframe. Continued interview with the Laboratory Manager revealed she believed patient AMI profiles were late because the lab order originated in the ED. She stated when the patient's "label" printed for the repeat test, it printed in the ED indicating the patient was in still in the Emergency Department; however, by that time, some of the patients were admitted to the hospital and laboratory staff had to find the patient.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of a facility job description, and review of facility policy, it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility policy for four (4) of ten (10) sampled patients (Patient #1, Patient #2, Patient #3, and Patient #4). Nursing staff failed to ensure acute myocardial infarction (AMI) profiles were drawn within the ordered timeframe for Patients #1, #3, and #4. Nursing staff also failed to ensure Physician Consults were conducted within twenty-four (24) hours of the order as per facility policy for Patients #2 and #4.

The findings include:

1. Review of the facility job description titled "Telemetry Registered Nurse," revealed the Registered Nurse (RN) would provide direct and indirect patient care in a critical setting. Continued review of the policy revealed the RN would communicate with physicians about changes in the patient's clinical condition, including hemodynamic monitoring, results in diagnostic studies, and symptomatology. The policy stated the RN was capable to respond quickly and accurately to changes in condition or response to treatment.

Review of the facility's policy titled "Laboratory/Nursing Information," revised 01/13/17, revealed that timed or urgent tests must be collected at a specific time to ensure appropriate patient treatment. This included such tests as acute myocardial infarction (AMI) profiles. The policy stated timed blood samples for testing would be collected within a one-hour window (30 minutes before or 30 minutes after the given time.)

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 02/22/17 through the Emergency Department (ED) to Telemetry with a diagnosis of unstable Angina. Continued review of the medical record revealed the resident's physician ordered an AMI profile. The blood for the first test was drawn on 02/22/17 at 10:15 AM with an order for a repeat level to be conducted in three (3) hours (which would have been at 1:30 PM) and six hours from the initial test (which would have been at 4:30 PM.) Further review of the record revealed the third test was not drawn until 5:23 PM (approximately one hour later than ordered.)

Review of the medical record for Patient #3 revealed the facility admitted Patient #3 on 03/30/17 to the Telemetry Unit from the ED with diagnoses that included Heart Failure, Hypertension, Chronic Pain, and Anxiety. An initial AMI profile was conducted on 03/30/17 at 9:15 PM with an order for a repeat level to be conducted three (3) hours from the initial draw and six hours from the initial draw (which would have been at 12:15 AM and 3:15 AM). Further review of the record revealed the AMI profile was drawn at 9:15 PM, 12:36 AM, and 4:05 AM (50 minutes later than ordered).

Review of the medical record for Patient #4 revealed the facility admitted Patient #4 on 02/22/17 to the Telemetry Unit from the ED with diagnoses that included Syncope, COPD, and Dehydration. An initial AMI profile was ordered and conducted on 02/22/17 at 8:01 PM with an order for a repeat level to be conducted three (3) hours from the initial draw (which would have been at 11:01 PM). Further review of the record revealed the AMI profile was drawn at 8:01 PM and 12:00 AM (one hour later than ordered).

2. Review of the facility's policy titled "Physician to Physician Consults," revised 08/13/13, revealed all consultations would be performed and documented within a twenty-four (24) hour period or more expeditiously as indicated by the level of urgency communicated by the ordering physician.

Review of the medical record for Patient #2 revealed the facility admitted Patient #2 on 03/31/17 to the Telemetry Unit from the ED with diagnoses that included Dizziness, Symptomatic Bradycardia with Dual Chamber Placement (low heart rate despite a pacemaker), and Postural Hypotension (low blood pressure). A cardiac consultation was ordered on [DATE] at 12:30 PM; however, the cardiac consultation was not conducted until 04/03/17 at 8:45 AM (two days and 20 hours after it was ordered.)

Review of the medical record for Patient #4 revealed the facility admitted Patient #4 on 02/22/17 to the Telemetry Unit from the ED with diagnoses that included Syncope, COPD, and Dehydration. A cardiac consultation was ordered on [DATE] at 11:15 AM; however, the cardiac consultation was not performed until 02/24/17 at 7:09 PM (32 hours after it was ordered.)

Interview with the Unit Manager of the Telemetry Unit on 04/04/17 at 10:35 AM revealed nursing staff could see physician orders on each chart; however, there was no way for them to track laboratory studies that were due for the patients on the unit. In addition, the Unit Manager stated orders for physician consultations came up on the specific physician's status board, but did not show on the nursing status board. Thus, nursing staff did not have the ability to track to ensure consultations were conducted in a timely manner.

Interview with the Chief Nursing Officer (CNO) on 04/05/17 at 3:00 PM revealed she understood all patient care was the responsibility of the RN assigned to each patient. Further interview with the CNO revealed that it was a "system" problem that made nursing staff incapable of ensuring all patient orders were conducted in a timely manner.