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.

NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 May 4, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, closed record review, grievance file review and staff interviews the hospital failed to ensure a written notice of resolution per policy for 2 of 3 grievance files reviewed (#56 and 51).

Review of hospital policy titled "PATIENT COMPLAINTS/GRIEVANCE" reviewed 01/09 revealed "c. Timeframe's for addressing and responding to grievances are as follows: 1. Acknowledgement of complaint - one (1) to two (2) work days or sooner assuming a contact number has been provided; 2. Completion of investigation - within forty-five (45) calendar days from receipt of complaint or sooner when possible; if the investigation cannot be completed within 45 days, the status of the investigation will be communicated. 3. Written Response - within 45 - 60 calendar days or sooner when possible."

1. Review on 05/05/2011 of a grievance file for Patient #56 revealed a grievance was received by the hospital on [DATE] from the patient's legal representative concerning quality of care issues at the hospital. Further review revealed the grievance was investigated by the hospital. Further review revealed no available documentation the hospital provided a written notice of resolution to the patient's representative as of 05/05/2011 (120 days after grievance received).

Interview with Nursing Administrative Management Staff on 05/05/2011 at 1000 revealed the grievance file contained no documentation of a written resolution/response provided to the patient's family.

2. Review on 05/05/2011 of a grievance file for Patient #51 revealed a grievance was received by the hospital on [DATE] from the patient's legal representative concerning quality of care issues at the hospital. Further review revealed the grievance was investigated by the hospital. Review revealed a meeting was held with the patient's legal representatives on or about 02/17/2011. Further review revealed no available documentation the hospital provided a written notice of resolution to the patient's representative as of 05/05/2011 (87 days after grievance received).

Interview with Nursing Administrative Management Staff on 05/05/2011 at 1000 revealed the grievance file contained no documentation of a written resolution/response provided to the patient's family.

Interview on 05/05/2011 at 1200 with Risk Management staff confirmed a written letter of resolution had not been provided to the family as of 05/05/2011.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

The hospital failed to have an effective system for the notification of patient's next-of-kin and/or legal representative upon the patient's admission/death for 1 of 2 patients who expired in the emergency department (#51).

The findings include:

Review of hospital policy "DEATH NOTIFICATION POLICY," Number 6.24, effective 11/13/2006, revealed "...Procedure: 1...Decedent is received in Morgue area from nursing floors or outside transportation services...^. Advise dispatcher or relieving person of any next-of-kin contacts or attempts that have been made to contact someone...C. Notification process 1. Multiple attempts will be made to identify next-of-kin, contact numbers and notification of next-of-kin. Risk Management, the Patient Advocate, Switchboard and Administrative Operations Officers will be resources to Special Police (hospital police staff). 2. A friend of the decedent will be considered if next of kin cannot be located. If that fails, the Captain or Chief of Special Police Services will be notified of the attempts. 3. Local law enforcement will be notified to check decedent's resident for a point of contact if needed. 4. If all attempts are unsuccessful, then Department of Social Services (DDS) will be contacted after the decedent has been here for 10 business days.

Closed emergency department (ED) record review for Patient #51 revealed a [AGE] year old man brought to the ED via ambulance, in cardiac arrest on 02/01/2011 at 1035. The patient subsequently expired at 1043. Review of nursing documentation at 1050 revealed "unable to contact family at this time." Further record review revealed the body was transferred to the morgue on 02/02/2011 at 0136. Record review revealed no documentation the patient's next-of-kin and/or legal representative was notified of the patient's death/admission while in the emergency department. Review of a Release of Body form and Report of Death form, completed by the ED staff, revealed no documentation the next-of-kin had been notified by the ED staff.

Review on 05/04/2011 of hospital documentation revealed the patient's cousin had received notification from an outside source about the patient's admission to the hospital. Further review revealed the cousin called the ED between 1330 to 1400 on 02/02/2011 and was placed on hold and then inadvertently disconnected. Further review revealed the cousin called back and was transferred to the Special Police. Review revealed a Special Police officer asked the cousin about organ donation and had assumed the family had been made aware of the patient's death. Further review revealed the officer realized the family had not been made aware of the patient's death. Review revealed the officer obtained the cousin's contact information and then contacted the Carolina Donor Services (CDS - contracted organ procurement agency) giving them the cousin's phone number. Further review revealed documentation CDS contacted the cousin regarding organ donation, and this upset the cousin, as she had just learned about the death. Review of the hospital documentation revealed the cousin visited the hospital on [DATE] to claim the body and personal belongings. Review revealed the body was released to a funeral home on 02/02/2011 at 1645. Further review revealed documentation the cousin found a piece of paper with her name and phone number on it and a piece of paper with a phone number and "Dad" written on it located in the patient's wallet. Further review of hospital documentation revealed the patient's cousin and aunt were very upset with how they had been informed about the patient's death. Review revealed a grievance had been filed.

Interview on 05/05/2011 at 0845 with the Nurse Coordinator for the night shift on 02/01/2011, revealed she had gone through the patient's wallet, found his drivers license and address. Interview revealed the patient's monies had been secured and no cards or notes with next-of-kin information had been identified. Interview revealed the ED staff had accessed the Internet in an attempt to locate next-of-kin. Interview revealed the staff found the patient's name and home phone number, attempted to call, and no one answered. Interview revealed, once the body is transferred to the morgue they (the ED nursing staff) no longer make attempts to contact the next-of-kin, the task of notification is given to the Special Police. Interview confirmed she had not done a thorough check of the patient's wallet. Interview revealed looking for identification and securing the patient's money was her main focus.

Interview with the Chief of Special Police on 05/04/2011 at 1455 revealed once a body is transferred to the morgue, the death notification process is the responsibility of the Special Police.

Interview on 05/05/2011 at 0905 with the Special Police officer working the night shift when Patient #51's body was transferred to the morgue revealed she had not been informed by the ED staff of the inability to notify the next-of-kin. Interview revealed she made no attempts to contact the patient's next-of-kin.

Telephone interview on 05/05/2011 at 0925 with the on-coming day shift Special Police officer on duty 02/02/2011 revealed she had not been made aware Patient #51's next-of-kin had not been notified. Interview revealed she made no attempts to contact the patient's next-of-kin.

Follow-up interview on 05/05/2011 at 0905 with the Special Police chief confirmed no attempts had been made to find the patient's next-of-kin, per Hospital policy, as they thought the family had already been informed by the ED staff. Interview revealed he and the ED Director had agreed the hospital needs a better system so this would not happen again in the future.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, medical record review and administrative staff interview, the hospital staff failed to assure the death of a patient that occurred while restrained and/or within 24 hours after being removed from restraints was reported to the Centers for Medicare Services (CMS) for 2 of 2 patients who expired in restraints (#57 and #58).

The findings include:

Review of the hospital policy, "Restraint Use for Adults and Children," revised 01/2008, revealed, "...VII. Death Reporting Requirements The Compliance Department staff will report the following information to CMS: Each death that occurs while a patient is in restraint or seclusion. Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. Each death known to the hospital that occurs within one (1) week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. Each death will be reported to CMS no later than the close of business the next business day following knowledge of the patient's death. The date and time that the death was reported to CMS will be documented on the patient's medical record..."

1. Closed record review on 05/05/2011 for Patient #57 revealed a [AGE] year-old admitted [DATE] with sepsis and hypothermia. Record review revealed a physician's order dated 03/19/2011 at 0600 for soft limb restraints and side rails to prevent the patient from pulling at lines/tubes and dislodging medical therapies. Record review revealed the patient remained in restraints until his death on 03/23/2011 at 0435. Record review revealed no documentation that CMS was notified of Patient #57's death while in restraints.

Interview on 05/05/2011 at 1000 with the hospital's regulatory compliance officer revealed, "I keep the reports related to death in restraints in my office then I send the reports to medical records to be scanned. The medical record for (Patient #57) is closed so the forms should be in the record". Interview confirmed there was no documentation in Patient #57's medical record of notification to CMS of the patient's death in restraints.

2. Closed record review on 05/05/2011 for Patient #58 revealed a [AGE] year-old admitted [DATE] with respiratory failure and renal failure. Record review revealed a physician's order dated 01/11/2011 at 1100 for soft limb restraints and side rails to prevent the patient from pulling at lines/tubes and dislodging medical therapies. Record review revealed the patient remained in restraints until his death on 01/12/2011 at 0345. Record review revealed no documentation that CMS was notified of Patient #58's death while in restraints.

Interview on 05/05/2011 at 1000 with the hospital's regulatory compliance officer revealed, "I keep the reports related to death in restraints in my office then I send the reports to medical records to be scanned. The medical record for (Patient #58) is closed so the forms should be in the record". Interview confirmed there was no documentation in Patient #58's medical record of notification to CMS of the patient's death in restraints.

NC 686