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Based on information received from the complainant, review of the hospital's grievance procedure and grievance files, and staff interview, the hospital failed to implement a process for prompt resolution of patient grievances for 1 of 1 patient (Patient #15) grievance received by an outside source. Failure by the hospital to recognize concerns brought by an outside source as a grievance has the potential to place all patients at risk of harm by allowing issues pertaining to patient care to go uninvestigated and unresolved.

Findings include:

Review of the hospital policy titled, "Grievance Procedure (Patient/Family)" occurred on 09/08/10. This policy, with a revised date of May 2010, stated, ". . . Policy: 1) It is the policy of Triumph Hospital - Central Dakotas to resolve patient and visitor concerns in a prompt and courteous manner, and to follow a uniform procedure for resolving grievance (sic) that cannot be resolved at the point of encounter or service by staff present . . . 5) This policy and procedure applies to all patients, patient representatives, family members, and visitors . . .

Definitions: 1) A Patient Grievance is a formal or informal written or verbal complaint . . . regarding the patient's care . . .

Procedure: Triumph Hospital - Central Dakotas staff who become aware of a patient concern or complaint about patient care . . . are authorized to attempt to resolve the concern or complaint as promptly as the circumstances allow and in a reasonable manner. . . . 2) Approaches for resolving complaints and grievances may include the following . . . Face-to-face meetings with the patient . . . 3) Documentation of complaints, including the patients or visitor's name, the date and all other pertinent information including how the concern or complaint was resolved, must be completed . . . 8) All oral or written grievances will be reviewed, investigated, and resolved within a reasonable time frame . . . 9) The CEO [chief executive officer], or designee, will inform the grievance (sic) in writing of the outcome of the grievance . . . ."

Review of information submitted by the complainant (by e-mail, dated 09/02/10) to the Department of Health, Division of Health Facilities identified the following allegations (grievance): On 08/19/10, representatives from Centers for Medicare/Medicaid Services (CMS), North Dakota Department of Human Services (DHS) and a local provider agency visited with Patient #15 regarding his care and his desire to return to the community. During this visit, Patient #15 expressed concerns regarding his care to these representatives. Patient #15 shared concerns about therapy services and the length of time he has had to remain in bed. He expressed "strong unresolved feelings" about the loss of his ability to use his legs and he indicated the hospital has not provided any counseling or assistance in dealing with these unresolved feelings. Patient #15 also indicated he and a male staff member don't get along and have "exchanged some strong words."

On 08/20/10, the representative from DHS contacted Patient #15's Case Manager (Staff #2) and discussed the concerns Patient #15 shared during the visit the day before. The Case Manager indicated she would check into the issues and follow-up with the DHS representative. The DHS representative indicated no follow-up occurred.

Review of the hospital's grievance files from January 1, 2010 through present occurred on 09/08/10. The hospital provided no file/information for Patient #15.

During interview on 09/09/10 at 7:35 a.m., the Chief Executive Officer (#7) indicated she was not aware of any concerns shared by the CMS/DHS staff pertaining to Patient #15.

During interview on 09/09/10 at 9:00 a.m., about Patient #15, the Case Manager (#2) indicated Patient #15 has unresolved issues. This staff member indicated she spoke to the physician regarding psychiatric services, but he felt Patient #15 did not need psychiatric services. This staff member also discussed the lack of therapy services for Patient #15 and indicated the patient refused them in the past so the physician would not order any. This staff member provided information addressing the concern about the male staff member. Staff member (#2) confirmed she did not provide follow-up information to the DHS representative.

Another interview occurred on 09/09/10 at 10:00 a.m., with the Case Manager (#2) and the Chief Clinical Officer (#1). The Case Manager confirmed she spoke to the DHS representative on the phone regarding Patient #15, but indicated she did not consider the information as a grievance. The Case Manager said she did not speak to Patient #15 about the concerns expressed, but spoke only to the doctor. The Chief Clinical Officer indicated the staff should have considered the information about Patient #15 as a grievance. This staff member also indicated facility staff did not follow their grievance policy.

Based on information received from the complainant, professional reference review, record review, and staff interview, the hospital failed to ensure 1 of 1 inpatient (Patient #5) and 1 of 14 closed record patient (Patient #15), or their representatives, actively participated in the development and implementation of their plans of care to address and meet their individualized psychological and mental health needs. Failure of the hospital to address the psychological and mental health needs of Patient #5 and #15 did not allow these patients to achieve and or maintain their highest level of psychological well being.

Findings include:

Review of information submitted by the complainant (by e-mail, dated 09/02/10) to the Department of Health, Division of Health Facilities identified the following allegation (grievance): On 08/19/10, representatives from Centers for Medicare/Medicaid Services (CMS), North Dakota Department of Human Services (DHS) and a local provider agency visited with Patient #15 regarding his care and his desire to return to the community. During this visit, Patient #15 expressed concerns regarding his care to these representatives. Patient #15 expressed "strong unresolved feelings" about the loss of his ability to use his legs, and he indicated the hospital had not provided any counseling or assistance in dealing with these unresolved feelings.

On 08/20/10, the representative from DHS contacted Patient #15's Case Manager (#2) and discussed the concerns Patient #15 shared during the visit the day before. The Case Manager indicated she would check into the issues and follow-up with the DHS representative. The DHS representative indicated no follow-up occurred.

- Review of Patient #15's closed medical record occurred on September 08-09, 2010. The medical record identified an admission date of 02/11/10 and the hospital discharged the patient on 08/30/10 to a skilled nursing facility. Patient #15's medical diagnoses included multiple chronic Stage 4 pressure ulcers to sacrum, right and left hip, right and left heel, and right and left lateral lower extremities, osteomyelitis, paraplegia, anxiety, and insomnia.

Review of Patient #15's physician orders identified the provider prescribed Zoloft 50 milligrams (mgs) daily on 03/15/10. Lippincott's 2009 Nursing Drug Handbook, page 609, identified one of the indications for using Zoloft is in the treatment of depression, and the usual dosage ranges from 50-200 mgs daily.

Review of Patient #15's Physician Progress Notes and Interdisciplinary Progress Notes included the following entries pertaining to the patient's psychological and mental health:

02/21/10 - " 'I'm dying today' - perks up easily . . . Discussion - Very few options available. Encouragement attempted. Pt [patient] NOT suicidal."
03/30/10 - "Still [with] pain issues. Gets bored when awake which is alleviated [with] narcotics . . . ."
03/31/10 - "Still [with] pain - really has nothing to do to keep busy. Pt bored. . . ."
04/06/10 - ". . . Agree pt is a 'Professional Patient' [with] lots of excuses. Good mood tonight."
04/19/10 - ". . . c/o [complaints of] getting more depressed - encouraged not to look back [at] past [and] look [at] future [and] trying to heal. . . ."
04/29/10 - ". . . Pt [patient] talked about his accident and concern about not healing as well as he would like."
05/13/10 at 11:25 a.m. - ". . . Does admit to some difficulty [with] thought . . . but still agrees to follow through. . . ."
05/13/10 at 3:00 p.m.- ". . . A little depressed now that he understands upcoming amputation - Still want to do it though. . . ."
05/14/10 - "Anxious - a little scared but still wants to go through [with] amputation. . . ."
06/09/10 - "Very stressful day . . . Discussion of events. Encouragement given. . . ."
06/10/10 - "Alert, talkative. A bit distressed . . . ."
07/01/10 - ". . . Reports had appoint [appointment] with ortho [orthopedic specialist]. Pt is disappointed re: [regarding] time spent. . . ."
07/23/10 - "Called by [patient name] regarding medication. Discussed with him regarding appropriate behaviors. Reported he was calling the nurse inappropriate names. Explained this would not be tolerated. Explained also time of medications that the nurses have a schedule regarding administration of meds [medications]. We did adjust his meds within past 2 weeks so he's not being woken early in the morning. All his AM meds are at 9 AM. Continues to be upset when awoken at 9 AM. Discussed this is very inappropriate for him to yell at staff. . . ."
08/02/10 - ". . . Angry - a little confused. . . ."
08/11/10 - ". . . Pt wanted to vent on how life is treating him in general. . . ."
08/20/10 - ". . . just talking about how life is the same day after day. Just needed someone to listen to him vent."
08/28/10 - ". . . We spent close to an hr [hour] talking about his move [and] the feelings he has . . . talked about being depressed as he/his life isn't going anywhere and about leaving staff here behind as he has been here a long time. . . ."

Review of Patient #15's care plan showed hospital nursing staff identified a nursing diagnosis of "Psychosocial/alteration in coping mechanism" on 03/15/10 and initiated nonspecific interventions/actions of: "1. Listen and encourage patient to verbalize feelings. 2. Support patient's sense of autonomy by involving the patient in decision making. 3. Assist patient in developing an Advance Directives (sic) as needed. 4. Address patient's spiritual, religious, and cultural needs. 5. Arrange for clergy/religious rituals as needed. 6. Provide and promote emotional support and refer to case management as needed. 7. Assess for signs and symptoms of abuse/neglect and communicate concerns to case management."

Patient #15's care plan, from March through August 2010, failed to include any individualized interventions or actions to address or help Patient #15 cope with his prolonged hospital stay and feelings of depression, anxiety, and hopelessness.


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During interview on 09/09/10 at 9:00 a.m. regarding Patient #15, the Case Manager (#2) indicated he has unresolved issues and won't let go. This staff member indicated she spoke to the physician, and the physician felt Patient #15 did not need psychiatric services.



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- Review of Patient #5's current medical record occurred on September 08-09, 2010. The medical record identified an admission date of 08/13/10 and medical diagnoses included respiratory failure, chronic obstructive pulmonary disease, and pneumonia.

A psychiatry progress note, dated 08/17/10, stated, ". . . poor eye contact, minimal interaction [with] staff, appears emotionally blunted [versus] [questionable] cognitive impairment. Suggest antidepressant to address anxiety/depression."

A psychiatric consult note, dated 08/18/10 identified, ". . . Treatment Plan: . . . she certainly appears to be depressed, which would be quite common given her lengthy medical concerns. As she does not appear sedated, nor is she appearing excessively anxious, we are, for now, going to continue with lorazepam [antianxiety medication] . . . and Haldol [antipsychotic medication] . . . We are going to add to it Lexapro [antidepressant medication]. Psychiatry will continue to follow."

During interview, the afternoon of 09/09/10, an administrative nursing staff member (#3) stated the physician discontinued Lexapro on 08/20/10 due to the patient appearing oversedated.

On 08/26/10, the hospital transferred Patient #5 to another facility after she experienced an unresponsive episode. Patient #5 returned to the hospital on 08/29/10.

The physician's History and Physical, dated 08/29/10, stated, ". . . 4. The other concerns of course are her actions. She basically takes off the O2 sat [oxygen saturation] monitor to get people to come into the room and then does not do anything other than stare off into the distance. . . . She does not initiate or have anything to do with conversation and continues to seemingly purposely pull off leads. She appears to be more alert than one might expect . . . She seems or appears to be not content with the situation that she is in. . . . NEUROLOGICAL: Mentally she . . . distances herself from any form of conversation; however, will communicate when she needs something or has an interest in something. IMPRESSION: . . . 4. She also seems to have fairly marked depression with avoidance type mental status at this point."

Physician's Progress Notes, identified the following:
08/30/10 - ". . . Remains distant . . ."
09/01/10 - ". . . Pt [patient] continues to give no assistance [and] pushes away treatment . . . A [assessment] . . . 2 Withdrawn/depressed . . ."

The social services progress notes, dated 08/13/10 to 09/07/10, showed no documentation of Patient #5's psychological status, as addressed in the physician's progress notes. During interview, the afternoon of 09/09/10, the social worker (#3) stated she was not aware that Patient #5 was withdrawn or depressed. The staff member (#3) stated she does not read the physician's progress notes or the nurse's notes and instead relies on the staff to let her know if the patient has any problems or concerns.

Psychiatry staff did not re-evaluate Patient #5 after the physician discontinued the antidepressant and the patient continued to show signs and symptoms of depression. The hospital failed to address the patient's mental health needs, allowing her to achieve or maintain her highest level of psychological well being.

Based on information received by the complainant, record review, professional reference review, and staff interview, the hospital failed to meet nutritional needs in accordance with recognized dietary practices for 1 of 1 closed record (Patient #13) of a patient with a pressure ulcer who experienced weight loss. Failure to provide interventions to meet nutritional needs can result in weight loss and delayed wound healing.
Findings include:

Review of information submitted by the complainant (by e-mail and telephone, dated 07/19/10) to the Department of Health, Division of Health Facilities identified the complainant had concerns regarding his son's (Patient #13) weight loss while he was at the hospital. The complainant stated his son lost 15 pounds due to "not having proper food to eat" and that the loss of weight "made his system weak."

Mahan, Escott-Stump "Krause's FOOD, NUTRITION, & DIET THERAPY," 10th Edition, W.B Saunders Company, page 370, states "Weight loss (in lbs [pounds] or kg [kilograms]) reflects an immediate inability to meet nutritional requirements, and thus may indicate nutritional risk. The percentage of weight loss is highly reflective of the extent and severity of an individual's illness. . . . Significant weight loss is interpreted as a 5% loss over 1 month; a 7.5% loss over 3 months; or a 10% weight loss over 6 months. Severe Weight loss is considered to be >5% weight loss over 1 month; >7.5% weight loss over 3 months; or >10% weight loss over 6 months. . . ."

- Review of Patient #13's closed medical record occurred on September 08-09, 2010. The medical record identified an admission date of 02/12/10 and medical diagnoses including paraplegia (since 2006) and bilateral posterior thigh ulcers. A progress note by the wound specialist, dated 02/18/10, identified "Stage 4 pressure ulcers bilateral posterior thighs." The Centers for Medicare/Medicaid Services defines a Stage 4 pressure ulcer as full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

The initial nutritional assessment, dated 02/16/10, identified an admission weight of 165 pounds (lbs), an 18% weight loss (35 lbs) from his usual weight of 200 lbs. The consultant dietitian (#7) calculated additional protein needs for wound healing based on 1.2 - 1.5 gm/kg. The consultant dietitian (#7) documented "suspect severe protein calorie malnutrition" and recommended vitamin D, vitamin C, and zinc sulfate.

Additional nutritional progress notes during Patient #13's hospital stay identified the following:
02/26/10 - "Wt [weight] 156.8 lbs (02/20/10) [down] 8.2 lbs since 2/12/10. . . . "Diet: Regular - Pt [patient] is eating 80% of meal trays. Good appetite. Vit D [and] zinc supplements started on 02/17/10. No change needed."
03/02/10 - "No weight available. . . . Diet: Regular - Pt is eating 85% of meal trays. Good appetite. Tolerating snacks/supplements well. Plan - weigh pt."
03/10/10 - "Diet: Regular - Pt is eating about 35% of day meal trays. Pt sleeps most of the day. Nursing reports that pt eats at night time. Wt 143.4 lbs (3/6/10) Wt has [decreased] 13.4 lbs since 02/20/10 156.8. . . ."
03/16/10 - "Wt 143 lbs (3/13/10) Wt has remained stable since last week. . . . Diet: Regular. Pt is eating 47% of meal trays on average. Pt also receives outside food. Plan - D/C [discontinue] zinc sulfate . . . ."

Patient #13's weight decreased from 165 lbs on 02/16/10 to 143 lbs on 03/13/10, a 22 pound (13%) weight loss in less than a month (13% is severe weight loss).

During interview, the afternoon of 09/09/10, the consultant dietitian (#7) stated she started Patient #13 on Ensure Plus (a nutritional supplement) after the initial assessment, but confirmed she did not document this intervention in the medical record.

Review of the "Patient Care I [intake] & [and] O [output] Sheet" identified no documentation of Patient #13 consuming a morning, afternoon, or an evening snack on 30 of the 35 days of his hospitalization. The I & O Sheet does not identify if Patient #13 drank the nutritional supplement.

The medical record showed the hospital provided a "Regular Diet" to Patient #13, but provided no evidence of additional interventions for weight loss and/or wound healing, such as additional eggs at breakfast, extra calories, additional supplements, etc.

During interview, the afternoon of 09/09/10, the consultant dietitian (#7) stated the documentation in the medical record "does not indicate that there was any interventions on my part" regarding Patient #13's weight loss.

Based on observation, review of policy and procedure, and staff interview, the hospital failed to ensure proper implementation of infection control policies by housekeeping staff on 2 of 2 days of survey (September 08-09, 2010). Failure to implement and follow appropriate infection control policies/practices has the potential to allow transmission of organisms from patients to staff, other patients, or visitors placing all individuals at risk of infection.

Findings include:

Review of facility policy titled "Techniques & [and] Recommendations for Isolation Precautions" occurred 09/09/10. This policy, reviewed/revised 11/01/02, stated, "Handwashing: Handwashing is the single most important means of preventing the spread of infection. . . . Hands should be washed between all patient contacts . . . Bagging Of Articles: Used patient care articles need to be enclosed in an impervious bag before they are removed from the patient's room. Such bagging is intended to prevent inadvertant [sic] exposures of personnel to articles contaminated with infective material and prevent contamination of the environment. . . . Dressings And Tissues: All dressings, paper tissues and other disposable items should be bagged and disposed of in accordance with hospital practices. . . . "

Review of facility policy titled "Infections: Modes of Transmission" occurred 09/09/10. This policy, reviewed/revised February 2010, stated, "Policy/Purpose: The purpose of this document is to outline precautions necessary to reduce the risk of acquiring and/or transmitting infection among patients and healthcare workers. . . . Procedure: . . . Contact transmission - occurs when there is skin-to-skin surface contact or contact with a contaminated intermediate object . . . contaminated . . . dressings, or gloves, etc. . . . This is the most frequent mode of transmission in healthcare-associated infections . . . Transmission-based precautions are types of isolation needed to interrupt at least one of the 5 modes of transmission . . . Contact isolation: Is used for patients know [sic] or suspected to be infected with pathogens that are transmitted direct (i.e. hands of healthcare workers) or by indirect contact with the patient's environment. . . . Put a Contact isolation sign on the patient door. . . . Do hand hygiene before donning PPE [personal protective equipment] and entering the room. Put on gloves before entering the patient's room . . . Put on a gown before entering the patient's room . . . Remove gloves and discard, then remove gown . . . Immediately after leaving the patient's room, hands must be degermed with an alcohol hand antiseptic or antimicrobial soap . . . Hand hygiene is critical to prevent the spread of organisms transmitted by skin to skin contact or by contact with contaminated equipment. . . ."

Review of facility policy titled "Isolation/Precautions Guidelines" occurred 09/09/10. This policy, reviewed/revised 07/09/04, stated, "Purpose: To prevent the spread of infections. . . . Principal: . . . Contact Precautions apply to: 1. Infectious agents transmitted by direct contact (skin to skin contact) and physical transfer of the organisms to another person. 2. Infectious agents transmitted by contact with a contaminated object in the environment. . . . Contact Precautions: 1. In addition to Standard Precautions, use Contact Precautions for specified patients known or suspected to be infected or colonized with . . . microorganisms that can be transmitted by direct contact with the patient . . . or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment. . . . B. Gloves and Handwashing: In addition to wearing gloves as outlined under Standard Precautions, wear . . . when entering the room. . . . Remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. . . . ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments. C. Gown: In addition to wearing a gown as outlined under Standard Precautions, wear a gown . . . when entering the room if you anticipate that your clothing will have contact with the patient, environmental surfaces, or items in the patient's room . . ."

During the entrance conference on 09/08/10 at 10:30 a.m., facility staff identified the hospital's current census as 12 patients, 10 of which were placed under isolation precautions for protection of patients, staff, and visitors against infection.

- Observation during medication pass with a nursing staff member (#6), on 09/08/10 at 3:37 p.m., in Patient #8's room, showed a housekeeping staff member (#4) entered Patient #8's room, picked the contents (disposable gloves, isolation gowns, paper towels, etc.) out of the garbage bag, took the contents out of the room, and disposed of the contents in a large black garbage bag. The garbage bag sat on the floor in the hallway next to Patient #8's room. The housekeeping staff member (#4) then picked up the garbage bag and proceeded down the hall to the next patient room.

Observation of Patient #8's room showed a "Contact Precautions" sign on the door. The sign indicated staff must don a gown when entering the patient's room, gloves when staff suspect touching the patient's intact skin or surfaces and articles in close proximity to the patient, and must remove gloves and gown, and perform proper hand hygiene before leaving the patient's room. Observation of the housekeeping staff member (#4) upon entering Patient #8's room to collect the garbage, identified the lack of a gown, and showed only donned gloves on the staff member (#4). Observation identified the housekeeping staff member (#4) placed the contents of garbage against her arms and clothing as she took them out of Patient #8's room, and showed the staff member (#4) failed to remove her gloves and perform hand hygiene after leaving Patient #8's room. It cannot be determined if the housekeeping staff member (#4) removed her gloves and performed hand hygiene after she proceeded down the hall and prior to entrance into the next patient room.

- Observation of a nursing staff member (#8) completing a dressing change to Patient #9's Peripherally Inserted Central Catheter (PICC), on 09/08/10 at 3:45 p.m., showed a housekeeping staff member (#4) entered Patient #9's room, grabbed the contents out of the garbage bag liner, took the contents out of the room, and placed the contents in a large black garbage bag, which sat on the floor in the hallway/corridor.

Observation of Patient #9's room showed a "Contact Precautions" sign on the door. Observation of the housekeeping staff member (#4) upon entering Patient #9's room to collect the garbage, identified the lack of a gown, and showed only donned gloves on the staff member (#4). Observation identified the housekeeping staff member (#4) placed the contents of garbage against her arms and clothing as she took them out of Patient #9's room, and showed the staff member (#4) failed to remove her gloves and perform hand hygiene after leaving Patient #9's room. It cannot be determined if the housekeeping staff member (#4) removed her gloves and performed hand hygiene after she proceeded down the hall and prior to entrance into the next patient room.

- Observation of the nursing floor, or patient care area, of the hospital on 09/09/10 at 9:30 a.m., showed a housekeeping staff member (#4) mopped the floors in Patient #10's room and bathroom, and identified the lack of a gown on the staff member (#4) while this occurred. The housekeeping staff member (#4) also lacked a gown while she cleaned and mopped the room and bathroom of Patient #7. Observation of Patient #7 and Patient #10's rooms showed a "Contact Precautions" sign on each door. The signs indicated staff must don a gown when entering the patient's room.

- A random observation of the patient care area of the Hospital on 09/09/10 at 10:00 a.m., showed a housekeeping staff member (#5) mopped the floor in Patient #8's room, and identified the lack of a gown on this housekeeping staff member (#5). Observation of the door to Patient #8's room showed a "Contact Precautions" sign posted on the door.

During interview on 09/09/10 at 3:10 p.m., when informed of the observations involving the housekeeping staff members (#4 and #5), an administrative nurse (#1) stated the practice is "unacceptable." The administrative nurse (#1) confirmed prior to entering an isolation room, all staff must observe contact precautions and apply a gown and gloves; and prior to leaving an isolation room, all staff must observe contact precautions and remove the gown and gloves and perform hand hygiene, especially if proceeding to another patient room.

Failure to observe established infection control practices by 2 of 3 hospital housekeepers responsible for cleaning all patient rooms on any given day, placed all hospital patients, staff, and visitors at risk of infection.


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