HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that grievances involving patients were thoroughly investigated for complainant resolution, in 3 of 3 patient grievances (Patient #'s 1, 2 and 3), in a total of 10 patients.

Findings include:

Record review of "Policy: Patient Grievances, Concerns and Advocacy Services-Hospital, reviewed/revised 6/2018" revealed "6. The Patient Family Representative or designee must investigate and resolve the patient's grievances within a reasonable time frame, generally defined as 7 days..."

1) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on that 3/19/19 Patient #1's family member filed a formal grievance regarding Patient #1's bruises. There was no documented evidence that Patient #1's injuries of unknown origin were thoroughly investigated to rule out improper care.

2) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/30/19 that Patient #2 filed a formal grievance regarding privacy issues of staff not knocking before coming into bathroom, and the initiation of the stump (leg amputation) shrinking process in anticipation the prosthetic device placement. There was no documented evidence of an investigation regarding bathroom privacy issues to ensure patient privacy or for complaint resolution. There was no documented evidence the hospital conducted an investigation into when or how prosthetic follow-up would be done. There was no documented evidence that Patient #2 was given any follow-up information regarding the details of how the prosthetic evaluation would be conducted.

During interview with Patient #2 on 4/30/19 at 9:40 a.m., Patient #2 stated "They (the hospital) told me everything about my stump would be done here, now I find out they don't do it here. I don't know what is going on."

3) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/30/19 Patient #3's family member filed a formal grievance regarding Patient #3's recent fall. There was no documented evidence the hospital thoroughly investigated the fall and reported complaint resolution to Patient #3's family member.

During interview with Director of Patient Relations C on 4/30/19 at 3 p.m., C stated "Patient complaint issues were given to hospital staff, but I did not do any follow-up to see that investigations were conducted and documented."

During interview with Chief Operating Officer A on 4/30/19 at 3 p.m., A stated "We do not have documentation of the investigations done for these patient (Patient #'s 1, 2 and 3) concerns.

Based on record review and interview, the hospital failed to ensure written notices were provided to complainants filing grievances with the hospital, in 3 of 3 patient grievances (Patient #'s 1, 2 and 3), in a total of 10 patients.

Findings include:

Record review of "Policy: Patient Grievances, Concerns and Advocacy Services-Hospital, reviewed/revised 6/2018" revealed "7... In the resolution of a grievance, the hospital must provide the patient with the written notice of it's decision. Written notice must include: a. Hospital contact person, b. Steps taken on behalf of the patient to investigate the grievance, c. Results of the grievance process, d. Date of completion..."

1) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/19/19 Patient #1's family member filed a formal complaint regarding Patient #1's bruises. There was no documented evidence the hospital responded to the family member of Patient #1 by providing a written resolution decision notice.

2) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/30/19 Patient #2 filed a formal complaint regarding privacy issues of staff not knocking before coming into bathroom, and the initiation of stump (leg amputation) shrinking process in anticipation the prosthetic device placement. There was no documented evidence the hospital responded to Patient #2's grievance by providing a written resolution decision notice.

3) Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/30/19 Patient #3's family member filed a formal complaint regarding Patient #3's recent fall. There was no documented evidence the hospital responded to the family member of Patient #3 by providing a written resolution decision notice.

During interview with Director of Patient Relations C on 4/30/19 at 3 p.m., C stated "I did not provide a written notice of resolution for these patients (Patient #'s 1, 2 and 3)."

Based on record review and interview, the hospital failed to ensure that it investigated all patient injuries of unknown origin, in an attempt to prevent further injury from occurring, in 1 of 2 patient injuries (Patient #1), in a total of 10 patients.

Findings include:

Record review of "Policy: incident Report (IR), reviewed/revised 6/2018" revealed "A. All staff report incident or unusual occurrences: 1. Involving patients, residents, staff and visitors. Staff also report unusual occurrences that do not result in injury, but had the potential for resulting in injury."

Record review of "Nursing Progress Notes" on 3/18/19 at 10:55 p.m. revealed "...Patient has two 1 inch in diameter round brown colored bruises to patellar knee extremity. Patient has square-shaped blue area to left lower extremity by anterior calf...The bruises are new..."

Record review of the hospital's incident/accident reports for the past 6 months (November 2018 through March 2019) revealed no documented evidence of a report regarding Patient #1's new injuries.

Record review of the hospital's complaint/grievance file ("2019 Grievance Log") revealed on 3/19/19 Patient #1's family member filed a formal complaint regarding Patient #1's bruises. There was no documented evidence that Patient #1's injuries of unknown origin were thoroughly investigated to rule out improper care.

During interview with Chief Operating Officer A and Nursing Director B on 4/30/19 at 3 p.m., B stated "An investigation was not done." A stated "There probably should have been a incident report fill out."

Based on record review and interview, the hospital failed to ensure physical holds, applied for the purpose chemical restraint, had a physician/licensed independent practicioner's order, in 1 of 1 patients requiring physical holds (Patient #4), in a total of 10 patients.

Findings include:

Record review of "Policy: Medical restraint-Hospital, revised/reviewed on 5/2018" revealed "Restraint: Any manual physical or mechanical method or device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely... If the use of a restraint is necessary, a physician will order restraint prior to the application."

Record review of the 4/20/19 at 6 p.m. "Nursing Progress Notes" revealed that Patient #4's physician was telephoned due to Patient #4 "screaming and yelling, started throwing things in room...into the hallway". The physician ordered "Haldol (antipsychotic) 2 mg. (milligram)" by intramuscularly injection. The notes revealed "Charge nurse had to hold patient's arms so writer could administer (Haldol)." There was no documented evidence of a physician's order for the physical hold used to restrain Patient #4's arms while the injection was given.

During interview with Director of Nursing B on 4/30/19 at 3 p.m., B stated "No order for the physical hold could be found."

Based on record review and interview, the hospital failed to ensure that the nursing/interdisciplinary team staff were provided with physiological and psychosocial behavioral management care planned interventions when medically-ordered psychology counseling occurred, in 1 of 1 patients receiving psychologist based counseling (Patient #2), in a total of 10 patients.

Findings include:

Record review of "Policy: Nursing Care Plan, reviewed/revised 12/2016" revealed "Goals are developed through the collaboration effort of the RN (Registered Nurse), patient and/or designated parties, and other members of the health care team... The plan will include strategies for promotion and restoration of health and prevention of further illness, injury, or disease."

Record review of the "Admission History and Physical" dated 3/9/19 at 2:55 p.m. revealed Patient #2 was admitted for right leg below the knee amputation and right foot amputation of all toes secondary to frostbite on 3/8/19. Record review of the 3/12/19 "Psychology Intake" report completed by Psychologist D revealed the reason for referral was "to assess and treat for depression". Record review of Psychologist D's documentation revealed initial assessment on 3/12/19 with continued visits on 3/26/19, 4/2/19, 4/8/19, 4/16/19, 4/17/19, and 4/22/19. There is no documented evidence of interdisciplinary care planning of behavioral interventions by Psychologist D that would assist nursing staff or other interdisciplinary team members to support Patient #2's physiological and psychosocial needs.

During interview with Staff Nurse G on 4/30/19 at 9:35 p.m., G stated that Patient #2 frequently vented anger and frustration at direct care staff over perceived lack of care.

During interview with Chief Operating Officer A on 4/30/19 at 3 p.m., A stated "The psychologist has not been writing care planning interventions that direct care staff can use to treat behavioral needs."

Based on record review and interview, the hospital failed to inform patients requiring discharge planning of their evaluation status, in 1 of 3 patient discharge plans (Patient #2), in a total of 10 patients.

Findings include:

Record review of "Policy: Discharge Planning-Hospital, reviewed/revised 3/2017" revealed under "Case Manager Responsibilities, 1. Discuss with the patient/patient representative, discharge goals and assessments required to determine the hospital's ability to establish and meet discharge goals."

During interview with Patient #2 on 4/30/19 at 9:40 a.m., Patient #2 stated "They (the hospital) told me everything about my stump would be done here, now I find out they don't do it here. I want to be discharged to the VA (Veterans Administration) so I can start the shrinking process to get my prosthesis. I don't know what is going on. They told me I ran out of hospital days and I am ready to go." When Patient #2 was asked what goals had to be met at this hospital before discharge could be attained, Patient #2 stated "I don't know, they don't tell me nothing."

Record review of the "Admission History and Physical" dated 3/9/19 at 2:55 p.m. revealed Patient #2 was admitted for right leg below the knee amputation and right foot amputation of all toes secondary to frostbite on 3/8/19 due to homelessness. Record review of Patient #2's medical record revealed the following "Case Management Notes" documentation:
"4/10/19 at 3:30 p.m. - No significant changes or questions." written by Case Manager E.
"4/16/19 at 4 p.m. - Had patient to sign permission for VA to release records to assist in locating housing upon discharge- Patient #2 stated that one had already been signed but at my request signed another to make sure; Patient #2 expressed concerns that Patient#2 was not getting any "real help" re: prosthesis, I tried to assure patient we intend to see to needs." written by Case Manager F
4/17/19 at 12 noon - CM (Case Manager) spoke with patient, informed of CM change, patient was agreeable. No questions or concerns. Requesting d/c (discharge) to VA." written by Case Manager E.
4/24/19 at 12 noon - CM spoke with patient and updated patient on progress made towards d/c. No significant changes, no questions or concerns." written by Case Manager E. There was no documented evidence of a discharge planning assessment identifying hospital goals/interventions that would need to be met before discharge placement could be defined.

During interview with Case Manager E on 4/30/19 at 10:40 a.m., E stated that details on the updates given to Patient #2's regarding discharge plan status had not been documented". E verified that outside inquiries made on the patient's behalf had not been documented. When asked about VA contact, E stated that Patient #2 had another case manager (F) that recently left and provided no documentation of VA contact. E stated that Case Manager F left no documentation other than the 4/16/19 note in the "Case Management Notes".

During combined interview with Case Manager E and Patient #2 on 4/30/19 at 2 p.m., E told Patient #2 that discharge to the VA was not possible due to lack of service time. E stated that the hospital would prepare written information regarding discharge options for Patient #2.