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.

PALESTINE REGIONAL MEDICAL CENTER 2900 S LOOP 256 PALESTINE, TX 75801 April 5, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the facility failed to ensure a thorough review and prompt resolution of patient grievances concerning care and treatment in 1 of 24 sampled patients (Patient #2).


This deficient practice had the likelihood to cause harm in all patients.


Findings include:


Review of the facility's complaint/grievance "Tracking Log" revealed a complaint was received about Patient #2 on 01/17/2017 about quality of care.


Review of the complaint form dated 01/17/2017 revealed complaints about the staff being "rude and unprofessional. They were more interested in playing around instead of caring for the patients." According to the complaint Patient #2 was discharged home and "He was still in a lot of pain and could not move his arms, only a little movement at the fingertips." Patient #2 followed up with his primary physician and was sent to another hospital. Patient #2"s findings were "both shoulder were fractured."


Review of the facility's response letter dated 01/24/2017 revealed a statement that the medical director had investigated the matter thoroughly. The following was also documented " ....The nursing issues have been dealt with by the director of the emergency department. We do unfortunately have to limit the amount of visitors to no more than two per patient. It makes it hard to care for patients when they are too many people in the room, and we must also be considerate of out other patients ..... I have reviewed all of the x-ray reports from both visits and our findings were negative for any fracture or dislocation of either shoulder ..."


During an interview on 04/04/2017 after 10:00 a.m., Staff #2 (Emergency Director) confirmed receipt of the complaint and that she was in charge of investigating the nursing portion of the complaint and the allegation of staff being rude. Staff #2 reported she had not talked to the nursing staff about the allegation. There was no other documentation about the investigation. When asked what the final results were about the nursing portion of the complaint. Staff #2 talked about limiting the amount of family going back into the rooms and negative results of the x-rays. Staff #2 offered no additional information on the lack of nursing assessment of the level of pain on discharge. By not addressing all of the nursing part of the grievance, there still was no resolution.


During an interview on 04/04/2017 after 2:40 p.m., Staff #27 confirmed she took care of Patient #2 and spent the most time with him and the family. Staff #27 confirmed she was not asked anything about Patient #2's care by anyone. Staff #27 confirmed she had failed to document an assessment of Patient #2's pain level.

Review of a facility's policy named "Patient Complaints/Grievances" approved 01/2016 revealed the following:

a. Any grievance that places the patient in immediate jeopardy endangers the patient or has the potential for patient harm shall be investigated immediately.
b. The target for completion of investigation of all other grievances shall be seven (7) working days of receipt of the grievance.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure a registered nurse provided continual supervision and evaluation of the nursing care of a patient presenting to Emergency department with severe pain in 1 of 24 sampled patients (Patient #2)


This deficient practice had the likelihood to cause harm in all patients.

Findings include:


Review of emergency room notes revealed Patient #2 (MDS) dated [DATE] at 11:58 p.m. with complaints of bilateral should pain. Patient #2 was given an acuity level of 2 (Emergent). This assessment was performed by a registered nurse. The last documentation in the chart by the registered nurse was at 12:01 a.m.


On 01/07/2017 at 1:02 a.m, Staff #27 (licensed vocational nurse) documented that Patient #2 complained of pain in the left scapular and right scapular. At worst, pain level was 10 out of 10 on a pain scale.


Patient #2 was given some of the following medications by Staff #27 (licensed vocational nurse):
At 12:47 a.m., the anesthetic Viscous gel;
At 2:06 a.m., the anti- inflammatory agent Ibuprofen and the muscle relaxant Flexeril;
And at 3:53 a.m. the pain/ nonsteroidal anti-inflammatory agent Toradol.


Staff #27 documented that there was no adverse reaction for a response after the first three medication administration. On the last medication administration there was documentation that the pain was decreased. There was no documentation of how much.


Patient #2 was discharged at 4:17 a.m. by Staff #27. There was no documentation of an assessment of the pain level in the shoulders.


Review of another hospital's records dated 01/14/2017 (7 days later) revealed Patient #2 presented with complaints of pain in the shoulders. Patient #2 was admitted after more test determined he had bilateral shoulder fracture-dislocations.

During an interview on 04/04/2017 after 2:40 p.m., Staff #27 confirmed she took care of Patient #2 and spent the most time with him and the family. Staff #27 confirmed she had not been asked about Patient #2's care by anyone. Staff #27 confirmed she had failed to document an assessment of Patient #2's pain level.