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.

NORTH CAROLINA BAPTIST HOSPITAL MEDICAL CENTER BOULEVARD WINSTON-SALEM, NC 27157 Feb. 4, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on hospital policy review, medical record review, grievance log review, and staff interview, the hospital staff failed to provide a written notice of its decision following submission of a verbal grievance for 1 of 2 patients (Patient # 3) with formal complaints.
The findings include:
Review on 02/03/2016 of the hospital's policy titled "Medical Center Patient Grievance Process" last reviewed May 2013 revealed, "...2) Definitions....If verbal complaints cannot be resolved..., requires investigation, and/or requires further actions for resolution, then the complaint will be handled as a grievance...Grievances also include situations where a patient or patient's representative alleges abuse or neglect, whether written or verbal. A complaint/grievance is considered resolved when the appropriate follow-up measures have been taken and response communicated to the patient and/or legal representative...3) Policy Guidelines... D. Complaints/grievances will be promptly investigated and response given to the patient within an average of seven (7) working days...All grievances will be responded to in writing upon resolution, and will include the steps taken to investigate the grievance, the results of the grievance process, date of completion, and the name of a contact person..."
Review on 02/02/2016 of Patient #3's "Pulmonary Admission History and Physical (H&P)" performed by NP #1 on 12/03/2015 at 2345 revealed a 53 y.o. male with a history of a brainstem CVA (stroke) in 2011 with loss of the ability to understand or express speech and right sided paralysis and weakness, diabetes (>500), high blood pressure, congestive heart failure, and irregular, rapid heart rate (as high as 180's) was transferred to the named hospital for treatment of "thyroid storm" (life threatening overactive thyroid), blood infection, and ongoing elevated temperature (102.8). Review revealed Patient #3 presented on 4L (liters) of oxygen (O2); however, during ongoing evaluation and treatment, O2 was increased to 12L with noted thick sputum production. Given the "declining status," Patient #3 was transferred to the hospital's Medical Intensive Care Unit (MICU) for "elevation of care." Review of the "Medical Intensive Care Unit Team B History and Physical" performed by Resident #1 on 12/04/2016 at 0455 revealed that upon arrival to the MICU, Patient #3 was unresponsive to verbal and physical stimulation. Following discussion with family, including guardian, consent was obtained for placement of a breathing tube secondary to acute respiratory failure. Continued review revealed that following stabilization, Patient #3 underwent surgical removal of the thyroid on 12/08/2015.
Review on 02/02/2016 of the "Nursing/Ancillary Note" by RT #1 dated 12/09/2015 at 1032 revealed, "Pt (patient) accidentally extubated (breathing tube out of place) during echo (echocardiogram: study of the heart) RT (respiratory therapist) called to bedside...MD's at bedside..." Review revealed Patient #3 was able to breath independently and was not immediately reintubated. "Critical Event Note" by RN #1 dated 12/09/2015 at 1033 revealed "Accidental extubation (breathing tube dislodged). Pt (patient) placed on NC (nasal cannula: breathing device)..." Review of the "Otolaryngology (ear and throat) Daily Progress Note" by Resident #2 dated 12/09/2015 at 1310 revealed "extubated this morning...and has not required re-intubation...Neck incision clean, dry and intact." Review of the "Nursing/Ancillary Note" by RT #2 12/09/2015 at 1751 revealed "Pt reintubated...No respiratory distress noted. Review of the nursing progress note by RN #1 dated 12/09/2015 at 1748 revealed "Pt intubated without complications. VSS (vital signs stable)..." Nursing progress note at 1752 by RN #2 revealed "Increased swelling around surgical wound. ENT (ear, nose, and throat) at bedside to evaluate. No intervention at this time. Will monitor for stridor (breathing noise made with obstructed airway) or further swelling." Continued review revealed over the course of the night, increased swelling and bleeding was noted and subsequently required emergency surgery on 12/10/2015 for removal of a blood clot and repair of a bleed in the surgical site. Further review revealed Patient #3's health continued to deteriorate and a hospice consult was placed following consultation with the guardian and family members. Review revealed Patient #3 was discharged home with hospice on 12/16/2015 and expired later that same day.
Interview on 02/03/2016 at 1150 with the hospital's Director of Patient/Family Relations revealed there was no contact by a member of the Patient/Family Relations department with the family during hospitalization or noted complaints related to the care of Patient #3. Interview revealed on 12/24/2015, family member called and requested a meeting with the medical staff following discharge regarding concerns that Patient #3's "right shoulder may have been dislocated under our care. (Family member) felt like it happened about the same time the breathing tube came out." (Family member) was advised the guardian may need to be involved and (family member) shared they were not sure the guardian would want to be involved. Interview revealed Advocate #1 consulted MD #2 on 12/29/2015 who deferred to the attending physican (MD #3) for consultation. MD #3 was consulted on 12/30/2015. Interview revealed the hospital's Risk Manager was also consulted on 12/30/2015 "regarding dislocated shoulder concerns." Interview revealed on 01/04/2016, MD #3 contacted (family member) and "had a long discussion" and concerns were believed to have been addressed at that time. Interview revealed on 01/05/2016 MD #4 was consulted and asked to review the chest x-rays taken during Patient #3's hospitalization to determine whether any may have captured the shoulder and if so, determine whether there was evidence of injury. X-rays were reviewed by MD #3 01/06/2016 and both shoulders were partially imaged on all studies. "There is no shoulder dislocation any time on any of the films. (Advocate #1) advised the family member we were unable to confirm a should injury and categorized the inquiry as a complaint. I feel like we should have handled it as a grievance, which would've entailed a written summary of our actions and findings." Interview revealed all the steps of a grievance were followed; however, "we are lacking in final correspondence."
Interview on 02/03/2016 at 1450 with Advocate #1 revealed (family member) called and spoke with the House Supervisor on 12/24/2015; however, the message was not passed on to the Patient/Family Satisfaction department. Interview revealed (family member) called and spoke with Advocate #1 advising Patient #3 had expired and shared concerns "regarding the shoulder." Interview revealed (family member) requested a copy of the medical record (MR) and shared assignment of an executor had not been made and (family member) "wanted (Patient #3) examined." Interview revealed the family member verbalized concerns that Patient #3 was suffering from pain because of the shoulder during hospitalization . Family member verbalized concerns that the shoulder may have been dislocated during extubation. "Risk Management, consulting physician, and (MD #3) were all involved throughout the investigation. I felt like (family member) was still not satisfied so the Risk Manager had MD #4 review the x-rays. We revisited her concerns and I felt like at that point it was resolved. Looking back I probably should've documented my interactions and should've written a letter, but I did not."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on hospital policy review, medical record (MR) review, and staff interview, the hospital staff failed to ensure use of restraints were not written on an as needed basis (PRN) for 1 of 2 patients requiring restraints. (Patient #3)

The findings include:

Review on 02/02/2016 of the hospital's policy titled, "Restraint and Seclusion" last revised 07/2014 revealed, "... Discontinuation of a restraint or seclusion order discontinues the order. Reapplication of a restraint requires a new order... C. Ordering of Restraints or Seclusion 1. After an assessment has been completed, and alternatives to restraints have failed, the physician or LIP (Licensed Independent Practitioner) should order the restraint or seclusion... 2. The physician/LIP must indicate a clinical justification, time limit and the type of restraint to be used for the restraint or seclusion order... Restraints for Nonviolent Reasons...If restraint use is warranted for longer than 24 hours, the physician/LIP must do a face-to-face assessment of the patient, and a new Restraint Order is completed...F. MD (Medical Doctor) Documentation for Restraints or Seclusion... 1. The physician or LIP responsible for the care of the patient will document in a progress note at least every 24 hours restraints or seclusion are used: - A description of the patient's behavior and the restraint type used. - The patient's condition or symptom(s) that warranted the use of restraint or seclusion. - Alternatives or less restrictive methods attempted as applicable. - The patient's response to the restraint or seclusion used, including the rationale for continued use as applicable...I. Physician Education 1. Physicians and other LIPs authorized to order restraint or seclusion...must have a working knowledge of hospital policy regarding the use of restraint or seclusion, including ordering, documentation, and notification requirements..."

Review on 02/02/2016 of Patient #3's "Pulmonary Admission History and Physical (H&P)" performed by NP #1 on 12/03/2015 at 2345 revealed a 53 y.o. male with a history of a brainstem CVA (stroke) in 2011 with loss of the ability to understand or express speech and right sided paralysis and weakness, diabetes (>500), high blood pressure, congestive heart failure, and irregular, rapid heart rate (as high as 180's) was transferred to the named hospital for treatment of "thyroid storm" (life threatening overactive thyroid), blood infection, and ongoing elevated temperature (102.8). Review on 02/02/2016 of Patient #3's medical record revealed nonviolent, bilateral, soft wrist medical restraints were initiated 12/04/2015 at 0110. Review revealed the right soft wrist restraint was discontinued 12/04/2015 at 0700, and the left, on 12/08/2015 at 2100. Review revealed physician orders by Resident #1 for "Soft extremity - Wrist (Bilateral)" orders on 12/09/2015 at 0223 and 12/10/2015 at 0130, after the name patient had been released from all restraints, with no evidence to support a continued need. Review revealed both orders were reviewed and authorized by MD #2.

Interview on 02/04/2016 at 1055 with the hospital's Admin #2 revealed MD #6 was not available for clarification of restraint orders written 12/09/2015 and 12/10/2015 following discontinuation on 12/08/2015. Interview revealed the named patient was not in restraints after 12/08/2015.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on hospital policy review, medical record review, and staff interview, the hospital nursing staff failed to monitor and reassess vital signs and effects of pain medication, for 1 of 2 critical care patients. (Patient #3)

The findings include:

Review on 02/04/2016 of the hospital's policy titled, "Monitoring Patients in the Adult Critical Care Areas" last revised 09/2015 revealed "... C. Vital Signs: 1. Blood pressure, pulse, and respirations should be checked on admission and then routinely every hour unless otherwise ordered by provider or more often if patient's condition warrants... 5. Pulse oximetry (SpO2) should be monitored continuously and recorded hourly unless otherwise ordered by provider..."

Review on 02/04/2016 of the hospital's policy titled, "Pain Management" last revised 01/2015 revealed, "... 4. Policy Guidelines: f) Assessment is performed regularly on all patients... j) Reassessment of pain relief is performed at regular intervals...The patient's response should be assessed within one hour of any pharmacological intervention...

Closed record review on 02/02/2016 of Patient #3's "Pulmonary Admission History and Physical (H&P)" performed by NP #1 on 12/03/2015 at 2345 revealed a 53 y.o. male with a history of a brainstem CVA (stroke) in 2011 with loss of the ability to understand or express speech and right sided paralysis and weakness, diabetes (>500), high blood pressure, congestive heart failure, and irregular, rapid heart rate (as high as 180's) was transferred to the named hospital for treatment of "thyroid storm" (life threatening overactive thyroid), blood infection, and ongoing elevated temperature (102.8). Review revealed Patient #3 presented on 4L (liters) of oxygen (O2); however, during ongoing evaluation and treatment, O2 was increased to 12L with noted thick sputum production. Given the "declining status," Patient #3 was transferred to the hospital's Medical Intensive Care Unit (MICU) for "elevation of care." Review of the "Medical Intensive Care Unit Team B History and Physical" performed by Resident #1 on 12/04/2016 at 0455 revealed that upon arrival to the MICU, Patient #3 was unresponsive to verbal and physical stimulation. Following discussion with family, including guardian, consent was obtained for placement of a breathing tube secondary to acute respiratory failure. Continued review revealed that following stabilization, Patient #3 underwent surgical removal of the thyroid on 12/08/2015.

Review on 02/04/2016 of the vital signs flowsheet dated 12/12/2015 at 0800 revealed an arterial blood pressure (BP) reading of 202/80 (normal reading: 120/80-140/90) and 219/91 at 0900 with no evidence of a BP recheck or assessment of cause until 1000. Review revealed BP remained between 157-196 systolic and 64-81 diastolic until 1300 at which time the BP reading was 206/82 with no evidence of a BP check or assessment until 1400. Review revealed no evidence of physician notification of change in patient status.

Review of the Medication Administration Record (MAR) revealed Patient #3 received Tylenol 1000 mg at 1618 for pain with no evidence of nursing reassessment within one hour of administration. Review revealed no evidence of nursing reassessment within one hour of the pain medication administration.

Interview on 02/04/2015 at 1015 with the Medical Intensive Care Unit (MICU) Nurse Manager (NM), Director of Nursing (DON), and Assistant Nurse Manager (ANM) revealed the expected frequency of pain assessment is every four (4) hours in the MICU, regardless of the need, or lack thereof, pain intervention(s). Interview revealed the expectation is that a pain assessment also occurs within one (1) hour of pain medication administration. Interview revealed when vital signs are outside the expected "norm for the patient" an assessment is performed and re-evaluation of the vital signs should occur.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on hospital policy review, medical record (MR) review, observation, and staff interview, the hospital staff failed to maintain an accurate record for 1 of 11 patients (Patient #3).

The findings include:

Review on 02/02/2016 of the hospital's policy titled, "Documentation of Patient Care, Treatment, And Services" last revised August 2014 revealed, "...2) Definitions:...J) Authentication: Method to establish authorship and/or approval of medical record entries and to verify that an entry is complete, accurate, and final..."

Review on 02/02/2015 of the hospital's policy titled, "Petition for Interim Guardianship and/or Full Guardianship" last revised 09/2014 revealed"... 3) Policy Guidelines: ... G. Once a guardian has been appointed: 1. The guardian is the decision maker for the patient. 2. All contacts for continued care, as well as planning for the patient should occur with the appointed guardian..."

Review on 02/02/2016 of Patient #3's "Otolaryngology (study of ears and throat) Daily Progress Note" by Resident #2 on 12/09/2015 at 1310 and counter signed by MD #1 revealed "Subjective:...He was extubated this morning after rounds and has not required re-intubation...General: The patient...remained intubated and sedated at the time of our exam...Respiratory: Work of breathing was normal on the ventilator..." Continued review revealed reference to the guardian as various family members, Power of Attorney (POA), and Health Care Power of Attorney (HCPOA)", none of which were accurate, throughout the medical record, including demographics sheet. Review revealed a blank "Informed Consent - Request For Treatment" with "Verbal consent from (family member), who was not the guardian, 12/04/2015 at 1340" and signed by MD #5. Further review revealed the "Letters of Appointment General Guardian" was not readily available in the electronic medical record (EMR).

NC 411, NC 805 and NC 943