HospitalInspections.org

Based on document review and interview the facility failed to follow and enforce the established policy titled "Complaint/Grievance Process".
A review of the policy titled "Complaint/Grievance Process," revealed, Definition, Complaint: A written or verbal concern or objection from a patient or the patient's designated representative regarding quality or appropriateness of patient care that can be effectively addressed and resolved by informal means. Generally, a complaint may be resolved quickly by the staff member receiving the complaint. Procedure, .... Complaints are documented on an Occurrence Report and follow the occurrence management process (see policy "Incident/Occurrence")
A review of the policy titled "Incident/Occurrence Reporting," revealed, Procedure: 1. Basic Report Considerations and Responsibilities: a. Occurrences require written completion of an Occurrence Report. b. The hospital employee who identifies the occurrence is responsible for initiation the Occurrence Report and providing it to the immediate supervisor or department manager by the end of the working shift. c. The Department Manager/Supervisor is responsible for: Notifying the Risk Manager or designee of significant occurrences ...
An interview was conducted on 12/3/1013 via phone conversation, with patient #1's designated representative regarding care issues. Patient #1's designated representative revealed multiple complaints were voiced to staff #1 and to staff #5 regarding patient care issues. Patient #1's designated representative revealed as a result of the re-occurring care issues and complaints, the facility hired a private sitter to stay with patient #1.
A review of the facility's incident reports revealed, no reports were filed on behalf of patient #1.
An interview on 11/12/2013 in the conference room with staff #2 confirmed no reports were filed on behalf of patient #1.
An interview on 11/12/2013 in the conference room with staff #1 confirmed a private sitter to stay with patient #1. Staff #1 confirmed at the approval of staff #5 a private sitter was hired and paid for by the facility. Staff #1 was unable to provide details of why the private sitter was hired. Staff #1 was unable to recall details of the complaints. Staff#1 confirmed an Incident/Occurrence Report had not been filed.

Based on document review and interview the facility failed to:
A. follow and enforce the established policy titled "24 Hour Patient Care Documentation". As per the facility's policy, 9 of 9 (Patients #1,2,3,4,5,6,7,8,9) patients' medical records did not have the Registered Nurses co-signing or co-initialing the Licensed Vocational Nurses' (LVN) signatures.
A review of the policy titled "24 Hour Patient Care Documentation" revealed in general rule number 9, "Entries may be co-initialed to indicate agreement with the observation of another team member as per state or board regulations i.e. a Registered Nurse must co-initial system review observations with the LVN ......"
A review of 9 of 9 (#1,2,3,4,5,6,7,8,9) patients' medical record reveled, the Registered Nurse did not co-sign or co-initial the LVNs' signature to indicate agreement.
A review of the Texas Board of Nursing, 15.28 The Registered Nurse Scope of Practice, revealed:
Evaluation and Re-assessment
A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary.

Essential Skills Used in the Nursing Process: Communication
Communication is an essential and fundamental component used during the nursing process. The RN must communicate verbally, in writing, or electronically with members of the healthcare team, patients and their families in all aspects of the nursing care provided to patients. These communications must be appropriately documented in the patient record or nursing care plan. Because RNs plan, coordinate, initiate and implement a multidisciplinary team's approach to patient care, collaboration is a quality crucial to the communication process. When patient conditions or situations exceed the RN's level of competency, the RN must be prepared to seek out other RNs with greater competency or other health care providers with differing knowledge and skill sets and actively cooperate to ensure patient safety.

A review of the Texas Board of Nursing, 15.27 The Licensed Vocational Nurse Scope of Practice, revealed:

The LVN's scope of practice requires that his or her nursing practice be directed by an appropriately licensed supervisor, e.g. registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist [Nursing Practice Act (NPA) Sections 301.002(5), 301.353 and Board Rule 217.11(2)]. The licensed supervisor is responsible for overseeing the LVN's nursing practice and actively engages in a supervisory process that directs guides and influences the LVN's performance of an activity.
Evaluation
A critical and fourth step in the nursing process is evaluation. The LVN participates in the evaluation process identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes. The LVN may contribute to the evaluation phase by suggesting any modifications to the plan of care that may be necessary and making appropriate referrals to facilitate continuity of care.
Essential Skills Use in the Nursing Process: Communication
Communication is a fundamental component in the nursing process. The LVN must communicate verbally, in writing, or electronically with members of the healthcare team, patients and their families on all aspects of the nursing care provided to patients. Communications must be appropriately documented in the patient record or nursing care plan. Because LVNs are members of the healthcare team, provide nursing care, and contribute to the nursing process, collaboration is a quality that is crucial to the communication process. When patient conditions or situations have changed or exceeded the LVN's level of competency and scope of practice, the LVN must be prepared to seek out his or her clinical supervisor and actively cooperate to develop solutions that ensure patient safety.
An interview with staff #1, #2, and staff #3, on 11/14/2013 at approximately 3:00PM, in the conference room, confirmed, there was no Registered Nurse's co-initial with the LVN documentation of the 9 of 9 patients' medical records reviewed.

B. follow and enforce the established policy titled "Pronouncement of Death by Registered Nurse". Patient #7's medical record did not contain the required documentation for the pronouncement of death by the Registered Nurse.
A review of the policy titled "Pronouncement of Death by Registered Nurse, Procedure D" revealed, " Documentation of determination and pronouncement of death is to include the following:
1. Title: Pronouncement of Death
2. Vital Signs- ceased
3. Date of Expiration
4. Time of Expiration
5. Patient Name
6. Patient Room Number
7. Primary Physician
8. Organ Procurement ( ___ yes/ ___ no)
9. Autopsy ( ___ yes/ ___ no )
10. Justice of the Peace case ( ___ yes/ ___ no )
The above information is documented in the progress notes. Signature, printed name and title of the Registered Nurse making the entry are required."
A review patient #7's medical record reveled, the Registered Nurse did not document the required, "pronouncement of death, vital signs- ceased, date of expiration, time of expiration, patient name, patient room number, primary physician, organ procurement ( __ yes/___no), autopsy( ___ yes/ ___no), justice of the peace case ( ___ yes/ ___ no)."
An interview with staff #3, on 11/14/2013 at approximately 1:00PM, in the conference room, confirmed, there was no documentation by the RN as required by the facility's policy, "Pronouncement of Death by Registered Nurse".