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.

GRIFFIN MEMORIAL HOSPITAL 900 EAST MAIN STREET NORMAN, OK March 29, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to provide each patient a written notice of the investigational process and outcome of patient grievances for 71 of 71 grievance records reviewed.

This failed practice resulted in 71 patients who filed grievances to receive no communication from the facility regarding the steps taken to investigate nor results of the investigation and had the potential for all patients who filed grievances to receive no evidence of resolution.

Findings:

A review of 71 of 71 patient grievances from 09/02/17 to 03/11/18, showed no written response regarding any investigation conducted or decision concerning resolution.

A document titled, "Grievance Policy: Consumer Grievance", (revised 01/19/18) showed

I. valid grievances would be reviewed and an initial response provided within seven working days. If resolution was not obtained, the grievance response would be mailed to the residence or email address listed on the form.

II. all patients would be notified as to the outcome of their grievance

On 03/27/18 at 10:20 am, Staff F stated if grievances were resolved on paper, the patient would receive a copy of the grievance form completed by the patient. Staff F stated letters had been written to families or patients in the past regarding grievances, but it had been a long time.

On 03/28/18 at 1:45 pm, during a phone interview, Staff I stated after the physician had "done something" a grievance was considered resolved, "because once action had been taken" it was resolved. Staff I further stated resolved grievances were sent to him/her and he/she did not provide copies to patients.

On 03/29/18 at 11:20 pm, Staff R stated if a grievance was resolved "on paper", the patient would receive a copy of the grievance. Staff R stated letters regarding resolution of grievances had been written to patients and families "in the past". He/she further stated the process was different now and the patients were given a copy of the "Complaint/Grievance Form".
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, interview and observation, the hospital failed to:

A. follow its policy regarding preparation and administration of narcotics by ensuring narcotics were administered by the licensed nurse that prepared medication.

This failed practice had the potential for the licensed nurse administering the wrong medication to the wrong patient and possible narcotic diversions.

A policy titled "Medication Administration" says the nurse who prepared a medication must administer and document the medication.

On 03/27/18, the surveryor observed Staff Y administering oral narcotics that were taken out of package by another licensed nurse. The following oral narcotics were taken out of the package by Staff Z and administered by Staff Y: Klonopin 2mg, Ativan 0.5mg and Ativan 1mg.

On 03/27/18 at 2:45 pm, Staff Y stated the medications were already taken out of package by Staff Z. "Staff Z had to go to another unit. This is my unit. So, I double checked to make sure it was the correct medication. I could have said no to giving medication. I didn't pull the medications, so, I am not supposed to give the medication."

On 03/28/18 at 12:30 pm, Staff A stated "the nurse shouldn't have done that. We do not do that and its not our policy."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on record review and interview, the facility failed to ensure the physician signed telephone orders in accordance the medical staff policy and procedures for two of 20 patients (Patient #1 and 3).

Findings:

A policy titled "Griffin Memorial Hospital Medical Staff Rules and Regulations" stated telephone orders must be signed, dated and timed within 5 working days, excluding weekends and holidays.

A policy titled "Physician's Orders" stated all telephone orders shall be documented on the physician order form and authenticated with a physician's signature; signatures will be timed and dated within 2 working days, excluding weekends and holidays.

(The two policies contradict one another on the number of days the physician has to sign, date and time orders.)

Patient # 1

On 03/27/18, a review of orders for wound care, antibiotics, pain medication and transfer to another unit dated 03/21/18 (6 working days after order was initiated) was not signed by the physician.

Patient # 3

On 03/27/18, a review of an order for patient to be transferred to another unit dated 03/10/18 (12 working days after order was initiated) was not signed by the physician.

On 03/27/18, a review of an order for new blood pressure medication dated 03/05/18 (16 working days after order was initiated) was not signed by the physician.

On 03/28/18 at 12:30 pm, Staff A stated all orders should be signed by the physician.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on record review and interview, the hospital failed to:

A. Ensure the nursing staff completed weekly assessment documentation for chronic wounds for one of 20 patients (patient # 1).

This failed practice had the potential for increased risk for decreased healing of patient's wound or ineffective treatment regimen.

B. Ensure finger stick values and insulin administration were documented on diabetic flowsheet for one of 20 patients (patient # 6).

Findings:

A. Wound Assessment

A policy titled "Wound Care/Dressing Changes" stated a weekly assessment should be done on all chronic wounds, including measurement and description.

Patient # 1

On 03/27/18, a review of record showed no weekly assessment in patient's chart.

On 03/28/18, surveyor asked Staff A for weekly assessment of wound. Weekly assessment was not provided.

On 03/28/18 at 12:30 pm, Staff A stated there should be a wound assessment in chart, if not then there is a problem; "we consider the patient's wound to be chronic."

B. Diabetic Flowsheet

A policy titled "Diabetes Management" showed to document the results of all finger stick blood sugars on the diabetic record...document routine and short acting insulin on the diabeties portion of the graphic sheet and medication administration record.

Patient # 6

A review of diabetic flowsheet record showed:

Insulin administraton was left blank for the following days: 03/17/18 at 9:00 pm, 03/19/18 at 6:10 am

On 3/28/18 at 12:30 pm, Staff A stated those are deficits and it should be addressed.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on record review, interview, and observation, the hospital failed to ensure the pharmacist maintained a current and accurate record of the disposition of all scheduled drugs in a readily retrievable manner.

This failed practice had the potential for abuse and/or loss of controlled substances which had the potential to increase the risk of diversion by staff and the potential for patients' not to receive medication(s) as ordered.

Findings:

I. Narcotic count

A. A policy "Medication Errors" (review date 10/01/17), showed the pharmacy staff would work with physicians, nurses, administrators, and others to examine and improve systems to ensure that medication processes were safe.

B. A nursing policy, "Narcotics and Other Controlled Drugs" (revised 04/17), showed when the count was incorrect, the off-going nurse would immediately notify the unit Registered Nurse, the Nurse Coordinator/Nurse Manager, and the Pharmacy.

C. A nursing policy, "Narcotics and Other Controlled Drugs" (revised 04/17), showed the on-coming nurse would count the medication and would visually observe the number on the "Narcotic Count Sheet" with the off-going nurse. Documentation of the status of the count between off-going and on-coming licensed nurses would be recorded on the "Narcotic Count Sheet".

D. A policy, "Controlled Substances" (review date 08/28/16), showed the pharmacy would periodically reconcile the medication rooms' stock of controlled substances with outstanding "Narcotic Count Sheets".

E. A document titled, "Narcotic Check Sheet", from 09/21/17 through 03/09/18 showed:

1. no nurse signature for the on-coming shift at 6:30 am on 01/13/18
2. no nurse signature for the off-going shift at 6:30 am on 10/16/17, 10/28/17, 11/29/17, 12/30/17, and 03/03/18
3. no nurse signature for the off-going shift at 2:30 pm on 01/13/18
4. no nurse signature for the on-coming shift at 10:30 pm on 09/21/17, 10/15/17, 03/02/18, and 03/08/18
5. no documentation of correct count for the 6:30 am to 2:30 pm shift on 10/08/17 and 12/25/17.
6. no documentation of correct count for the 2:30 pm to 10:30 pm shift on 10/15/17 and 12/23/17.
7. no documentation of correct count for the 10:30 pm to 6:30 am shift on 09/21/17, 10/27/17, 11/28/17, 03/02/18, and 03/08/18.
8. on 12/07/17, the documentation of correct count was marked through with a straight line and the word "error" was documented.


F. On 03/28/18 at 10:30 am, Staff O stated nursing staff had "often" been reminded to place completed "Narcotic Check Sheets" into a slot in the medication room for pharmacy to collect. Staff O also stated he/she did not know why "Narcotic Check Sheets" dated back to July 2017 were in the medication room.

G. On 03/29/18 at 9:00 am, Staff H stated his/her primary focus was the refrigerator temperature and outdated medications. Staff H further stated neither him /her, nor the pharmacy technicians monitored documentation of signatures or comments on the "Narcotic Check Sheets". He/she stated the "Narcotic Check Sheets" were the Chief Nursing Officer's responsibility.

H. On 03/29/18 at 1:30 pm, Staff A stated a blank signature space or a blank correct count space on "Narcotic Check Sheet" indicated the count was not done. Staff A went on to say the "Narcotic Check Sheet"(s) found by the surveyor in the medication room "should" have gone to Quality.

I. On 03/28/18 at 8:15 am, the surveyor observed incomplete "Narcotic Check Sheets" in the medication room, dated July 2017 to current, which lacked verification that the narcotic count was correct.


II. Audits

A. A document titled "Medication System Audit Form" (a form utilized by Pharmacy and Nursing to verify Medication Rooms were meeting criteria, including, but not limited to: cleanliness, properly labeled medications, etc.) showed from 09/21/17 to current, on 09/21/17, 10/19/17, 11/28/17, 12/11/17, 01/22/18 and 02/12/18 "controlled substances are securely stored and accurately accounted for" with Staff H's signature only, a nurse's signature was not documented.

B. On 03/29/18 at 9:00 am, Staff H stated "I always" perform the "Medication System Audit" with a nurse, and "we" both sign the form. He/she stated a copy was kept in pharmacy and a copy was sent to the Chief Nursing Officer. Staff H stated he/she had performed the audits for the past year and a half and was the "only one" who did them. He/she further stated copies went to the Chief Nursing Officer for "their own" purpose and the results of the audit were not presented or discussed at Pharmacy and Therapeutics.

C. On 03/29/18 at 9:00 am, Staff H stated he/she could not explain the absence of a nurse's signature on the "Medication System Audit" forms on 09/21/17, 10/19/17, 11/28/17, 12/11/17, 01/22/18 and 02/12/18. He/she stated there was always a nurse present during the "Medication System Audit" of the medication room(s).