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 record review and interviews, the hospital failed to ensure the policy and procedure for complaints and/or grievances was followed for 1 (#1) of 5 (#1-#5) patients reviewed for complaints and grievances. Findings:

A review of the policy entitled "Occurrence Reporting" (EOC 3) presented by S10RN (Risk Manager) as the current policy in place, revealed, in part: "Definitions, A. Occurrence: Any event that could potentially or does adversely affect a patient or visitor that occurs within the hospital property or on the grounds and is not consistent with standard patient care or the routine operation of the hospital. It may or may not have resulted in injury, harm, or loss of property. C. Discovering Employee: The first employee on the scene of the occurrence. Procedures: 1. All occurrences must be reported, even if no bodily harm or property loss resulted, utilizing the standard Occurrence Report Form."

A review of the policy entitled "Patient and family Complaint/Grievance Process" presented by S10RN as the current policy in place, revealed, in part: "Purpose: To provide our patients and families with appropriative channels for communicating problems, issues, and/or concerns regarding the patient's care, abuse or neglect, ....To provide efficient and timely processing, tracking, and resolution of all patient complaints/grievances. Definition: A grievance, according to CMS CoPs (Centers for Medicare and Medicaid Services, Conditions of Participation) is a patient care complaint, either written or verbal, that is: Not resolved at time of the complaint by staff present; Postponed for later resolution; Referred to other staff for later resolution; Requires investigation; Requires further actions for resolution...."

Review of a "General Occurrence Report" regarding Patient #1 revealed the report was documented by S6RN on 01/07/15 for an incident which occurred in the ED on 12/27/14 at "around" 5:00 p.m. S6RN documented "Spouse used call bell to call nurse into room. When I walked into ER 5, patient was sitting at bedside on floor with spouse standing at her side. I asked patient and spouse what happened and spouse stated that patient was getting out of bed to go use restroom and she got weak and sat on floor. Patient did have small amount of loose stool on floor. S13RN walked into room and I asked her to get another nurse to help me lift patient to bed. Another RN came to assist me with lifting patient to bed. Patient cleaned and re-gowned, bed and floor also cleaned. Patient was on cardiac monitor and reapplied after changing patient."

A review of the medical record for Patient #1 revealed there was no documentation in the medical record indicating Patient #1 had been observed sitting on the floor next to her ED bed by the ED staff.

In an interview on 11/12/15 at 10:10 a.m., S6RN reviewed the occurrence report and indicated he did write the report for the incident which occurred on 12/27/14 because he was the nurse who answered the call light when it rang. He further indicated the patient, nor the husband, did not voice any complaints about the nursing call light/bell being answered promptly. S6RN indicated he did not complete an occurrence report at the time because the patient had not fallen, but had sat down on the floor, according to what Patient #1's husband reported to him. S6RN indicated that he had been off for several days, and while he was off, he was contacted by S10RN and questioned about the incident, and was instructed to complete an occurrence report upon his return to work on 01/07/15.

In an interview on 11/12/15 at 3:00 p.m., S10RN indicated she does not remember the event occurring on 12/27/14, but she confirmed that the documented date as resolved was 01/29/15, and S10RN also confirmed there was no written response sent to Patient #1's family at the conclusion of the investigation because she did not consider this a complaint and/or grievance. S10RN assumed she had apparently been informed by someone at some point in time that a fall had occurred in the ED, and she was looking for an Occurrence Report regarding a patient's fall in the ED and not a complaint from a family member regarding a patient falling. S10RN indicated the Risk Management Committee meets to review, discuss, and implement any actions warranted regarding all incidents and occurrences reported, and she assumed that when the committee reviewed the occurrence report, no further action was recommended or needed because the patient had not actually fallen. S10RN confirmed the Occurrence Report was not completed by the discovering employee at the time of the incident nor was it documented in the medical record, and the event should have been documented in Patient #1's medical record and the Occurrence Report completed at the time of the occurrence so that Patient #1's incident in the ED could have been investigated appropriately and in a timely manner.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered according to physician's orders for 2 (#1, #5) of 5 (#1-#5) records reviewed for medication administration in a total sample of 5.

Patient #1:
Review of the medical record for patient #1 revealed she was to be admitted to the hospital on a medical/surgical unit for observation with diagnoses which included Intractable Abdominal Pain with Nausea, Vomiting, Diarrhea, and Hypotension (related to the nausea, vomiting, and diarrhea).

Review of Patient #1's hospital admission orders written in the Emergency Department on 12/27/15 at 2:15 p.m. by S7MD revealed the patient was to be admitted to a medical/surgical unit for observation. The hospital admission orders written on 12/27/14 at 2:15 p.m. included an order, "Zosyn (broad-spectrum antibiotic) 4.5 gr (grams) IVPB (Intravenous Piggy Back) every 8 hours. Further review of the hospital admission orders revealed there was no documentation by the ED nurse that the Zosyn had been administered in the ED.

In an interview on 11/12/15 at 10:40 a.m., S12RN stated she was not aware of a policy and procedure regarding particular time frames as to when the ED nurses should start to implement inpatient admission orders written for patients while the patients are still in the ED awaiting a bed assignment and actually transferred to the assigned unit. She also indicated there is no log or documentation written in the patient ' s medical record stating if the patient is to be boarded in the ED until a bed becomes available; however, if the ED staff was instructed to "board" a patient in the ED, the ED staff would begin implementing all of the admission orders written for the inpatient admission. S12RN indicated it was the expectation that the ED nurse was to review all of the admission orders (for the receiving unit) and should start to implement the orders if there is a delay in getting the patient to the floor. S12RN reviewed the ED record for Patient #1 and confirmed the order for Zosyn written on 12/27/14 at 2:15 p.m. had not been administered in the ED. S12RN confirmed the first dose of Zosyn administered to Patient #1 was on 12/27/14 at 8:20 p.m. in the ICU.

Patient #5:
Review of the medical record for patient #5 revealed an admitted [DATE] with diagnoses including Acute Hypoxemic Respiratory Failure, Pulmonary Edema, Volume Overload, Multilobar Pneumonia, and Leukocytosis. Review of the physician orders (electronic) dated 11/02/15 at 2:17 p.m. revealed an order for "Tobramycin inj (injection) {Tobramycin Sulfate} Per Pharmacy Protocol 1st NOW Dose: 20 -100 mg (milligrams) Route: IVPB."

Review of MAR (Medication Administration Record) for Patient #5 revealed "Tobramycin Sulfate 360 mg = 109 ML(milliliters) IVPB once" was listed as being administered on 11/02/15 at 6:05 p.m. (3 hours and 48 minutes after the "now" dose was ordered).

In an interview on 11/10/15 at 12:25 p.m., S15RN indicated the order required the Pharmacist to complete the dosage and frequency of administration per Pharmacy Protocol for Tobramycin. She indicated that Tobramycin required Peak/Through levels for dosage titration. S15RN indicated that the order was completed by the Pharmacist at 3:00 p.m. and should have been administered at that time. S15RN indicated after review of Patient #5's MAR the IV (Intravenous) antibiotic was administered approximately 3 hours and 5 minutes after it was available from the hospital's pharmacy.

In a telephone interview on 11/10/15 at 4:00 p.m., S16Pharmacist indicated that a medication that is ordered "Now" should be administered within one hour of the order being received. S16Pharmacist indicated, after checking the computer system, the Tobramycin IVPB was available and scheduled for administration for 3:00 p.m.

In an interview on 11/10/15 at 4:05 p.m., S10RN (Risk Manager) verified that the medication was not administered timely.

Review of the hospital policy titled Medication Administration, revealed in part:
Medication will be administered in a safe and efficient manner. Prescribing Orders: STAT or Now orders - All STAT/Now orders are to be administered as soon as possible.

In an interview on 11/10/15 at 3:55 p.m., S10RN indicated that after review of the hospital's medication administration policy, the policy failed to indicate a specific time frame for "now medications."