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OCHSNER MEDICAL CENTER - BATON ROUGE 17000 MEDICAL CENTER DR BATON ROUGE, LA 70816 July 11, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify complaints as grievances in accordance with hospital policy for 1(S2) of 2 (S2, S5) patient complaints/ grievances reviewed.

Findings:

Review of the Hospital Policy titled, "Patient Grievance Management", revealed the following, in part:
III. Definitions
A. Patient Complaint- verbal communication to the hospital by a patient, or the patient's representative, regarding the patient's care or non- care issue that can be resolved immediately by the staff.
B. Patient Grievance- is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (wen the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation (CoP), or Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.

A review of the Hosptal Grievance log between 4/1/18 and 7/2/18 failed to reveal a formal grievance for Patiet S2.

In an interview on 7/9/18 at 1:30 p.m. with S4PtAdv, she confirmed the Hospital Grievance Log between 4/1/18 and 7/2/18 did not contain a Grievance related to Patient S2.

In an interview on 7/10/18 at 0915 a.m. S5RN stated he met with the family of Patient S2 about the following concerns.
a. One employee stated their back was hurt; therefore, they were not able to turn the patient;
b. Patient S2 had a bed sore and the facility was the "culprit";
c. Patient S2 was in the flat position with a nasogastric tube and tube feeding infusing.
S5RN further stated he apologized to the family, gave them his card and had to investigate the concerns. He stated it took longer than 1 day to complete the investigation and he did not follow up with the family nor did he send a letter to the family about his findings and actions.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1.) The RN failing to ensure there was documented evidence Patient S2 was repositioned at least every four hours as per the Nursing Care Plan,
2.) The RN failing to ensure there was documented evidence Patient S2 was turned ever two hours as ordered,
3.) The RN failing to ensure there was documented evidence S2's neurological assessments were completed every four hours as ordered for 1 (S2) of 5 patient records reviewed.

Findings
1.) The RN failed to ensure there was documentation to support Patient S2 was repositioned at least every four hours as per the Nursing Care Plan.
A review of Patient S2's Nursing Care Plan revealed an intervention to turn and reposition the patient often dated 4/4/18 (Note: with a pressure management surface turning/ repositioning may be extended up to a maximum of four hours based on patient condition).

A review of Patient S2's flow sheet revealed there was no documentation to support Patient S2 was turned/ repositioned at least every four hours on the following dates and times.
a. 4/4/18 at 11:30 a.m. patient was repositioned and then not again until 5:32 p.m. (6 hours)
b.4/6/18 at 7:30 a.m. patient was repositioned and then not again until 7:30 p.m. (12 hours)

2.) The RN failed to ensure there was documentation to support Patient S2 was turned ever two hours as ordered.

A review of Patient S2's Physician orders revealed on 4/7/18 at 4:52 a.m. order to turn Patient S2 every 2 hours.

A review of Patient S2's flow sheet revealed there was no documentation to support Patient S2 was turned every 2 hours as ordered on the following dates and times.
a. 4/8/18 at 5:00 p.m. patient was turned and then not again until 8:00 p.m. (3 hours)
b. 4/8/18 at 10:00 p.m. patient was turned and then not again until 4/9/18 at 8:00 a.m. (10 hours)
c.4/10/18 at 1:00 a.m. patient was turned and then not again until 5:45 a.m. (1 hour 45 minutes)
d. 4/11/18 at 5:00 a.m. patient was turned and then not again until 7:57 a.m. (1 hour 57 minutes)

3.) The RN failed to ensure there was documentation to support Patient S2's neurological assessments were documented every four hours as ordered.

A review of Patiet S2's Physician orders revealed on 4/3/18 at 10:25 a.m. an order for neurological (neuro) checks every four hours.

A review of Patient S2's flow sheet revealed there was no documentation to support neuro checks were completed on the following dates and times.
a. 4/8/18 at 3:00 p.m. neuro checks were documented and then not again until 8:37 p.m. (5 hours 37 minutes)
b. 4/9/18 at 7:49 a.m. neuro checks were documented and then not again until 7:44 p.m. (11 hours 55 minutes)
c. 4/9/18 at 7:44 p.m. neuro checks were documented and then not again until 1:00 a.m. (5 hours 44 minutes)

In an interview on 7/10/18 at 3:30 p.m. S7RN verified the above missing documentation.