HospitalInspections.org

Intakes: TN00035617


Based on policy review, document review and interview, it was determined the facility failed to ensure patient grievances were addressed and resolved for 1 of 1 (Patient #1) sampled patients with a complaint or grievance.

The findings included:

1. Review of the "Complaint And Grievance Process" policy revealed, "The Hospital has established a mechanism for receiving, acting upon, and responding to patients, families, and visitors expressing concern for patient treatment and all areas of quality care (the 'Grievance Process')...5. The hospital staff member receiving the complaint will address the concerns that are appropriate to that individual's area of responsibility, expertise, state practice guidelines, experience, and knowledge and can be addressed immediately...6. If a complaint cannot be resolved timely by the Hospital staff member, the staff member shall notify his/her supervisor and complete the Complaint and Grievance form. The form is then forwarded to the Hospital's Director of Quality Management or Chief Nursing Officer...7. The Director of Quality...and/or Chief Nursing Officer will investigate the concern or complaint...8. Once the investigation has been completed, the findings of the investigation will be discussed with the Hospital's CEO...10. The Director of Quality Management, along with the CEO, will prepare a written response to the patient's grievance...11. The written response must contain the following: a) A description of the issues raised by the grievance b) A description of the steps taken to investigate the issue c) The date the grievance was resolved...d) The name of a contact person at the hospital that the patient can call with additional questions...14. Patient complaints must be made part of the QAPI process..."

2. Review of the "Patient/Family Report" dated 12/9/14 revealed Patient #1 filed a grievance complaint as follows, "Patient states over past 3 days, staff members have been rude and unattentive to her [Patient #1] needs. States it takes hours to be cleaned after a bowel movement...Pt informed to call for charge nurse with any concerns as soon as possible...All current issues resolved..."

There was no documentation the facility conducted an investigation, identified issues or took actions to prevent further recurrences in accordance with facility policy.

In an interview in the conference room on 4/22/15 at 9:00 AM the Chief Nursing Officer verified there was no documentation the complaint grievance was investigated or resolved.

Based on facility policy, record review and interview, the facility failed to ensure nursing staff consistently assessed 2 of 3 (Patient #1 and 2) sampled patients with wounds.

The findings included:

1. Review of the "Wound Assessment" policy revealed, "...Purpose: To provide guidelines for wound assessment...All patients admitted will have a skin assessment within 8 hours of admission and skin will be assessed every shift...The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color and surrounding tissue...
Pressure ulcer definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction...Pressure Ulcer Stages: Suspected Deep Tissue Injury [SDTI]: Purple or maroon localized area of discolored intact skin...Stage I: Intact skin with non-blanchable redness...Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed...Stage III: Full thickness tissue loss. Subcutaneous fat may be visible...Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle... Unstageable:Full thickness tissue loss in which base of the ulcer is covered by slough...and/or eschar..."

2. Record review revealed Patient #1 was admitted to the facility on 11/4/14 with the diagnoses of Respiratory Failure, Renal Failure, Coronary Artery Disease, Sternal Wound Infection, Sepsis, C- Difficile Colitis, Neuropathy, Diabetes, Hypertension, Gout, Polymyoneuropathy of Critical Illness, Stoke, Anemia, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Peripheral Artery Disease and Global Severe Weakness and Debility.

Review of the 11/4/14 wound assessment report revealed the patient was admitted to the facility with a stage II sacral "pressure ulcer" measuring 0.5 cm x 1.0 cm.

Review of the patient's sacral pressure ulcer wound assessment reports revealed the following:
11/17/14 - a 1.0 cm x 0.5 cm pressure ulcer. There was no documentation regarding the type of wound in accordance with facility policy.

12/29/14 - a 5.5 cm x 5 cm SDTI pressure ulcer with a beefy red (open) wound bed. There was no documentation regarding the location of the wound in accordance with the facility policy.

1/27/15 - a 12 cm x 15 cm ischemic "arterial" wound. The wound type was not identified in accordance with the facility policy.

2/4/15 - a 13 cm x 15 cm "venous" wound. A picture of the wound revealed the wound to have some undermining and tunneling. The wound was not assessed in accordance with the facility policy and the undermining and tunneling was not identified and described.

2/10/15 - an ischemic "diabetic" wound. The wound was not assessed in accordance with the facility policy.

2/19/15 - a 10 cm x 18 cm sacral venous wound with a small amount of serosanginous drainage and odor. The wound type was not identified in accordance with the facility policy.

3/9/15 - a 15 cm x 17 cm ischemic sacral wound with a large amount of foul smelling drainage. The wound had tunneling/undermining and was not assessed and described in accordance with the facility policy.

3. Record review revealed Patient #2 was admitted to the facility on 11/18/14 with the diagnosis of Respiratory Failure, Renal Failure, Chronic Obstructive Pulmonary Disease, Cardiomyopathy, Pulmonary Embolism with Vena Cava Filter, Lupus, malnutrition and C Difficile Colitis.

The physician's history and physical revealed the physician documented Patient #2 had a "stage II sacral pressure ulcer" on admission.

Review of the 11/24/14 wound assessment report revealed the wound nurse documented the wound was a SDTI. The nurse did not assess and describe the wound in accordance with the facility policy for an open wound.

Review of the 12/1/14, 12/15/14, 12/22/14, 12/29/14, 1/5/15, 1/13/15, 1/22/15, 2/9/15 and the 2/17/15 wound assessments revealed the wound was assessed as a SDTI and not identified in accordance with facility policy for an open wound over a bony prominence.

4. In an interview on 4/22/15 at 9:00 AM in the conference room the CNO verified the assessments were not complete and accurate.