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 review of hospital policy it was revealed that the governing body had not delegated in writing the responsibility of a grievance committee to review and resolve grievances. The hospital refers all grievances to the Patient Advocate who assigns a ticket owner to manage the grievance documentation and notify the managers of any involved departments/units. The Patient Advocate then provides a written response to the patient/patient representative. The hospital failed to meet regulatory requirements as the complaint/grievance policy does not delegate the responsibility in writing to a grievance committee.
Based on review of the hospital policy and an interview with the Director of Patient Advocacy on 8/5/15, it was determined that the hospital does not meet the expected length of time for resolution of grievances.

The hospital's Patient Complaint and Grievance Process, under procedure, states "Responding to Grievances #5. If the grievance cannot be resolved within 14 days , the Ticket Owner will inform the patient/patient's representative that the hospital is still working to resolve the grievance and will follow up with a written response, ideally within 30 days of initial receipt. " The hospital's response to complaints on average is within 24 hours and its response to grievance is 5-7 days. The hospital must attempt to resolve all grievances as soon as possible. The regulation requires the resolution of grievances and a written response on average within 7 days. If a grievance cannot be resolved within the 7 day time frame, the hospital will inform the patient or the patient's representative that the hospital will follow-up with written response within a stated number of days in accordance with the hospital's grievance policy.

Although the hospital on average is completing grievances with a letter to the patient/complainant their policy does not reflect regulatory requirement.
Based on review of the medical record and ACA for patient #2, an interview with the Director of Nursing, and review of the PI Council meeting minutes from 4/23/15, it was determined that nursing staff were not utilizing the Rapid Response Team (RRT) for deteriorating patient conditions. In addition, it was determined that the hospital has consistently failed to analyze and respond to adverse patient outcomes.

The hospital did not provide a policy about calling the Rapid Response Team or evidence of staff education about warning parameters that trigger a RRT to be called. Medical record review for patient #2 revealed that the hospital documented Modified Early Warning Scores (MEWS). This score was based on the patient's vital signs and level of consciousness. Scores of 4 or greater usually triggered the bedside nurse to call the Rapid Response Team (RRT), and indicated the need for interventions by physicians and/or the need for a higher level of care. Several vital sign documentation times noted MEWS scores of 4 for patient #2. However, the patient remained at the same level of care without a RRT being called, and was not monitored for deterioration of status.

The nurse's progress note on 1/10/15 at 11:43 PM stated the patient reported not being able to breathe (unsure of what time), a respiratory treatment was administered (given at 8:00 PM), oxygen saturations were low on 2 liters of oxygen so a non-rebreather oxygen mask (allows for a higher concentration of oxygen to be given) was placed on the patient, and the oxygen saturations improved. The nurse administered pain medication (morphine 2 mg) IV which was documented as being administered at 8:06 PM. The note also stated that the patient was anxious and was administered anti-anxiety medication (2 mg Ativan) intravenously (IV) at 10:07 PM, and then slept for 30 minutes. Patient #2 then woke up reporting not being able to breathe. The nurse notified a physician of the patient's high heart rate (no documentation about the nurse reporting respiratory effort of the patient) and that the physician had offered no new orders. According to documentation on 1/11/15 at 12:09 AM the patient was found unresponsive and a Code Blue was called. There was no documentation that the patient's heart rate and rhythm or oxygen saturations were continuously being monitored. Resuscitation efforts were unsuccessful and the patient expired at 12:23 AM.

An interview with the Director of Nursing on the morning of 8/5/15 revealed that the intensive care unit and the Emergency department "do well with calling a RRT but we are working with the medical-surgical and telemetry units to make earlier calls for RRTs especially when patients requiring additional oxygen demands and are wearing a non-rebreather mask for extended periods of time."

Review of the Quality Accountability Matrix for Reliable Care, which is a tool that the hospital uses to monitor and report the current quality measures, revealed that mortality is listed as a quality indicator under review. Evidence of compliance of MEWS standards is mentioned under the mortality matrix. However, no compliance data was provided to review if the MEWS standards are being monitored. The hospital is not reviewing or tracking data for compliance of calling the RRT and is not using MEWS as the standard for triggering an alert for a RRT to be called.

The lack of analysis of and response to serious adverse events create an unsafe environment for all patients. The conditions that have led to adverse patient outcomes are not being corrected.
Based on review of the Performance Improvement (PI) Plan for 2015, PI Council meeting minutes from 4/23/15 and medical records of six patients, and interviews with the Director of Nursing, the PI Coordinator and the Director of Quality Assurance on 8/4/15, it was determined that the hospital failed to measure, analyze, and track adverse patient events.

The hospital investigated staff-reported events in the form of a Root Cause Analysis (RCA) or an Apparent Cause Analysis (ACA). The PI Plan for 2015 indicated that RCA's are performed on adverse or sentinel events that result in death or permanent loss or disability of bodily function lasting more than 7 days. ACA's, also called "mini RCA's," were investigations conducted on identified near misses involving patients, visitors and staff.

The hospital has no clear policy listing which events are to be investigated and what documentation is to occur in the RCA or ACA investigation. An interview with the Director of Quality Assurance and the PI Coordinator on the afternoon of 8/4/15 revealed that incidents documented in Quantros (the event reporting database for staff) were reviewed by the Risk Managers, Quality and PI staff and the managers of the unit in which the event occurred. These staff members then determined which events were to be investigated as RCA's or ACA's. Only 1 documented RCA dated in the fall of 2013 and 2 documented ACA's for 2015 were provided for review during the survey. Review of the PI Improvement Council meeting from 4/23/15 revealed that there were five adverse events involving medication errors. There was no documentation provided that a RCA or an ACA was completed for these events.

Patient #2 had an event occur that, based on the written description in the PI Plan for 2015, should have been investigated as an RCA. Instead, the hospital performed an ACA which contained a written timeline of events during the patient's 3 day admission. There was no analysis of the events that caused the adverse event on the ACA document. The facility completed a "Lessons Learned" document based on the timeline of events which included improvement measures learned from the events. These "Lessons Learned" included physician ordering of specific lab-work based on patient presentation and that nursing is to alert the Rapid Response Team or physicians for patients requiring an increased oxygen demand. There was no compliance data to assure staff were educated or following the "lesson learned" guidelines.
Based on staff interviews, observations and review of policies, procedures, and other pertinent documentation during a Federal survey conducted on 8/4/15 to 8/5/15 the following concerns were identified:

1. Failure of the Governing Body to provide oversight of the Quality Assurance/Performance Improvement Program including:

a) Failure to ensure Quality Assurance/performance Improvement program was fully implemented to capture and assess problems, implement actions to correct the problems, and re-evaluate problems that were not resolved and
b) Failure to ensure that reportable events are investigated and reported to appropriate State/Federal agencies.

Review of the QI/PI initiatives, tracking, evaluation and actions revealed a system and process that does not involve all staff, administrative staff and the hospital board. The PI Plan 2015 does list which event parameters are investigated as RCA's versus ACA's. Per the Performance Improvement Coordinator, events from the event report system (Quantros) are reviewed by the Risk Manager, PI and Quality staff and department/unit managers in which the event occurred. This group then determines which events are to be investigated as RCA's and ACA's. The review revealed that there is no consistency or thoroughness in the process to identify events or perform RCA's or ACA's as well as reportable events.

Per review of Quality/Performance Improvement plan and an interview with the Chief Nursing Officer and the PI Coordinator on 8/5/15 the hospital had performed only 1 RCA (from 2013) and 2 ACAs (1/2015 and 2/2015). The PI coordinator stated that these are the only " incidents" on file. ACAs are "mini RCA's" according to the PI plan and the interview with the Quality Assurance Director on 8/5/15 . One ACA involved a patient being admitted for respiratory concern. The patient expired on Day 3 of admission. The ACA was a timeline of events but had no details about the investigation, the process review or the outcomes. A "Lessons Learned" form was completed that listed physician involvement and RN involvement in the incident. There was no follow-up data on the measures listed for education and improvement of process. The ACA for patient #2 revealed that no RRT (Rapid Response Team) was called even though the MEWS (Modified Early Warning Score-primary purpose is to prevent delay in intervention and transfer of critically ill patients) were elevated (4) and indicated calling of the RRT. A MEWS score of 4 or more indicates the need for more intense assessment such as initiation of interventions such as oxygen, IV, and medication management. The hospital had no compliance data to show RRTs are being effectively called. Also this death was not reported to the OHCQ Quality Assurance RN. The request for the total number of deaths/death log and total number of reviewed incidents RCAs or ACAs revealed other incidents/events including death that were not identified for review or reported to the OHCQ.

The failure of the hospital to have a clearly defined process for quality assessment/performance improvement with consistent application and oversight by leadership can directly affect patient outcomes including failure to capture potential trends and preventable adverse events.