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.

UNIVERSITY OF NORTH CAROLINA HOSPITAL 101 MANNING DRIVE CHAPEL HILL, NC 27514 Feb. 5, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on hospital policy review, grievance file review and staff interview, the facility failed to provide a written response to a grievance for 1 of 2 grievances reviewed (Patient #6).

The findings include:

Review of the hospital's "Complaints/Grievances" policy effective December 2013 revealed "... III. Policy A. Patient Grievances a. A "patient grievance" is a formal or informal written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made to (named hospital) by a patient, or the patient's Authorized Representative, regarding the patient's care, alleged abuse or neglect, issues related (named hospital's) compliance with the CMS (Centers for Medicare) Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489. ... c. A complaint is NOT a 'patient grievance' when: i. it is a verbal complaint about patient care that is resolved on the spot by staff present. ... e. i. ... In general, patient grievances should be resolved within seven business days... g. Once the investigation is complete, the Patient Relations Department will communicate the resolution of the grievance in writing in a language and manner that the patient understands. The written response will include the decision, the name of the grievance investigator, the steps taken to investigate the grievance issues, the results of the grievance process and the date of completion. ..."

Review of a grievance file revealed a grievance filed by Patient #6's mother on 11/04/2015 at 1339. Review of the electronic file revealed the patient's mother verbalized concerns to a Patient Relations staff member related to a delay in assessing and treating her son for a deteriorating condition associated with a feeding tube that was placed on three occasions. Review revealed she also complained about a nurse that provided care to her son. Review of the file revealed an investigation of the grievance that included information provided by one of the patient's physicians and a unit nurse manager. Review revealed the unit nurse manager had met with the patient's mother and counseled the involved nurse. Further review of the file revealed no written response sent to the complainant.

Interview on 02/04/2016 at 1450 with a Patient Relations Director revelealed that Patient #6's mother had met with a Patient Relations staff member on 11/04/2014 regarding her concerns about her son's feeding tube that was replaced three times and a nurse that had provided care to the patient. The interview revealed the patient's mother was crying when she presented her concerns and ended up thanking the staff member for listening. Interview revealed the grievance was closed. Interview revealed there was no written response sent to the mother regarding the grievance.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, patient and staff interviews, facility staff failed to provide an explanation for isolation precautions for 1 of 1 patients prior to initiating isolation precautions (#12).

Findings include:

Review of the hospital's policy and procedure titled "Isolation Precautions", effective date October 2015, revealed "...Patient education is essential to control the transmission of infections...The patient and their family should also be instructed regarding the need for isolation precautions to promote compliance...It is the responsibility of the physician to recognize the need for isolation and to order in CPOE (computerized physician order entry) the appropriate type of isolation precautions and reflect this appropriately in the electronic health record...the registered nurse should initiate the indicated isolation precautions and reflect this appropriately in the electronic health record...Use Contact Precautions (a set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact (touching) with the patient or the patient's environment), in addition to Standard Precautions (basic level of infection control that should be used in the care of all patients all of the time, for example, hand hygiene), for specified patients known or suspected to be infected or colonized with epidemiologically important (tendency for transmission in healthcare settings and difficult, or resistant to treatment with medications) microorganisms (e.g. MRSA (Methicillin-resistant Staphylococcus aureus is a bacteria responsible for several difficult-to-treat infections), VRE (Vancomycin-resistant enterococci, a type of bacteria that have developed resistance to many antibiotics, especially vancomycin)) that can be transmitted by direct contact with the patient...or indirect contact...with environmental surfaces or patient care items in the patient's environment...".

1. Closed medical record review of patient #12 revealed a [AGE] year old male who presented to the named facility's Emergency Department (ED) with a diagnosis of "Cellulitis (a common and potentially serious bacterial skin infection) of left lower extremity (leg)" per the "...Emergency Department Provider Note" dated 11/27/2015 at 1952 by MD #1 with an attestation (confirmed to be correct) by MD #2 on 11/27/2015 at 2118.. "...History" in the ED Provider Note revealed, "...past medical history of HIV (Human Immunodeficiency Virus; by damaging the immune system, HIV interferes with the body's ability to fight the organisms that cause disease. HIV is a sexually transmitted infection.)...recently diagnosed with left ankle cellulitis placed on azithromycin (antibiotic medication used to fight infection)...with worsening cellulitis, induration (hardening) and worsening pain....". Continued review of patient #12's medical record revealed a physician's order dated 11/28/2015 at 0149 by MD #3, "ED Admit Decision" and a note by MD #3 on 11/28/2015 at 0228 indicating "Pt (patient) admitted to (named facility's off-campus hospital). Review of the named facility's off-campus hospital's "...Medicine Admission Note" by MD #4, dated 11/28/2015 at 0421, revealed "...I believe this is cellulitis and not secondary syphillis...will treat with vancomycin (medication used to treat infections) to cover strep (Streptococcus: a group of bacteria that causes a multitude of diseases) and possible MRSA...Contact precautions to err on side of caution in case of MRSA...". Further review of patient #12's record revealed an order by MD #4 on 11/28/2015 at 0305 for "Contact isolation...Contact isolation should have the following: 1. Private Room 2. Gloves for Health Care Providers (HCP) when entering room 3. Gowns for HCP when anticipating contact with patient or environment 4. Visitors should follow institutional policies on PPE (personal protective equipment) compliance 5. Place Contact Precautions sign outside of the door...". No order for contact precautions was found in patient #12's ED record. Further review of patient #12's ED record did not reveal documentation by the ED nurses that patient #12 was on contact precautions. Review of patient #12's off-campus hospital record did not reveal documentation of patient education regarding MRSA and contact precautions.

Telephone interview on 02/03/2016 at 1140 with patient #12 revealed, MD #1 and her scribe (personal assistant to the physician who performs documentation in the electronic medical record) arrived to patient #12's room dressed in face masks, gowns, gloves and hair nets. Patient #12 reported after he was transferred to the named facility's off-campus hospital, "I had a floor to myself. Everyone who came in had masks, gloves, and gowns on. I assumed because I told them I was HIV positive they treated my like a plague-ridden thing."

Telephone interview on 02/04/2016 at 1550 with the Registered Nurse (RN #5) who cared for the named patient when he was initially transferred to the facility's off-site hospital revealed RN #5 remembered patient #12. RN #5 reported most of the time a patient will ask why they are on contact precautions. RN #5 stated, "I don't remember if I explained the precautions to the patient. It varies depending on the circumstances. The patient wanted to go to bed. We let him rest."

Telephone interview on 02/05/2016 at 1030 with an Infection Preventionist (IP #6) from the named facility revealed the ED staff should have put patient #12 on contact precautions because he had cellulitis that did not respond to previous antibiotic treatment.
Telephone interview on 02/05/2016 at 1108 with the facility's off-campus hospital's admitting physician (MD #4) revealed, "I am 95% certain I explained to the patient why he was on contact precautions."

NC 046 and NC 821