HospitalInspections.org

Findings:

Based on review of records and interview, the hospital failed to provide written notice of its decision, steps taken, results of the investigation and date of completion to 6 of 6 grievances received from patients (Patient #1, #14, #15, #16, #17and #19) regarding patient care.

Review of complaint received by Texas Department of Health Services, Patient #1 was discharged home from the facility on 03/05/10 in the am. She was admitted on 03/05/10 to another hospital for pneumonia that afternoon. On 03/06/10, Patient # 1's daughter complained to the CNO about discharging her mother from the facility in an unstable condition. The COO was asked whether the hospital received a complaint regarding Patient #1. He stated, "Yes."

Review of Complaint/Grievance Log showed:
Patient #14's wife complained to the facility on 03/15/10 that Patient #14 did not receive therapy for 2 days.

Patient # 15's family complained to the facility on 01/28/10 that the nursing staff is not responding to calls for help in a timely manner, not assisting the patient with activities of daily living, and not changing him and keeping him clean.

Patient #16's daughter complained to the facility on 03/08/10 regarding poor nursing care and that her mother's physical condition has worsened.

Patient #17 and her son complained to the facility on 03/07/10 regarding the lack of assistance from the staff when attempting to transfer and not answering the call system.

Patient #19 complained to the facility on 02/19/10 regarding the staff being rude and yelling at her for asking for too much assistance. She also complained of the call light not being answered in a timely manner.


Risk Management Policy, " Complaint or Grievance Policy, " dated, 04/01/07, requires " A 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 ...The CEO or designee is responsible for completing and send a letter to the complainant in response to a grievance ...The letter shall include the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the dates of completion ...The response letter shall be forwarded to the patient or patient representative no later than 7 days after receipt of the grievance. "

In an interview with Personnel #1, CEO, on the afternoon of 04/28/10, he was asked if a written notice of the hospitals decision that contained the required components of the grievance process was provided to Patient ' s #1, #14, #15, #16, #17 and #19. He stated, " No. "

Findings:

Based on review of records and interview, the hospital ' s nursing service continues to not be under the direction of a director of nursing service who is an RN (registered nurse) from 03/25/10 until 05/04/10.

Administrative Policy, " Administrative Coverage of Patient Care Services, " dated, 04/01/07, requires under, " The Nursing Department ...is directed by a Registered Nurse who is currently licensed in the State of Texas and qualified by advanced education and management experience. "

Job Description, " Chief Nursing Officer " , dated 01/01/07, requires under " Position Summary: Provides executive direction and oversight for nursing and other clinical services. Plans, organizes and directs management and delivery of quality patient care ... "

Review of the previous Chief Nursing Officer (CNO, Personnel #12) employee file, showed the last date worked at the facility as the CNO was 03/24/10.

In an interview with the CEO, (Personnel # 1), on the morning of 04/29/10, he was asked if the hospital has a designated Chief Nursing Officer or RN that is currently responsible for the operation of the nursing service. He stated, " No. " He was asked when the hospital last had a designated CNO. He stated, " The previous CNO left on 03/24/10. " He was then asked who is currently responsible for the daily operations of the nursing service and determining the staffing and/or scheduling needs of the nursing personnel to provide nursing care for the hospital. He stated, " The scheduling coordinator, in conjunction with the house supervisors determine the nurse staffing needs for the hospital. The house supervisors currently supervise the nursing service and report directly to me. "

Based on review of records, and interviews, the hospital failed to evaluate clinical activities for 41 of 41 (Personnel #13 through #54) nonemployee licensed nurses who provided direct patient care and/or supervised nursing staff between 03/01/10 and 03/31/10.

Findings Included:
Monthly Rehab 1 Unit Staffing sheets showed that the following nonemployee licensed nurses provided direct patient care:

LVN #13 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/10/10 and 03/31/10.
RN #14 worked the 7 pm - 7 am shift on the Rehab 1 unit on 03/01/10, 03/02/10, 03/04/10, 03/08/10, 03/09/10, 03/30/10, and 03/31/10.
RN #15 worked the 7 pm - 7 am shift on the Rehab 1 unit on 03/31/10.
LVN #16 worked the 7 pm - 7 am shift on the Rehab 1 unit on 03/15/10, and 03/30/10 and worked the 7am - 7 pm shift on 03/22/10 and 03/29/10..
LVN #17 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/11/10 and 03/30/10.
RN #18 worked the 7 pm - 7 am shift on the Rehab 1 unit on 03/30/10.
LVN #19 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/21/10 and 03/29/10.
LVN #20 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/04/10, 03/05/10, 03/07/10, 03/10/10, 03/11/10, 03/14/10, 03/15/10, 03/19/10, 03/22/10, 03/24/10, and 03/29/10.
LVN #21 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/28/10 and 03/29/10.
LVN #22 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/14/10, 03/15/10, 03/18/10, 03/22/10, 03/28/10 and 03/29/10.
LVN #23 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/29/10.
LVN #24 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/15/10, 03/19/10, 03/20/10, 03/21/10, 03/26/10, and 03/28/10.
RN #25 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/28/10.
LVN #26 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/16/10 and 7 am - 7 pm shift on 03/14/10 and 03/28/10.
LVN #27 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/12/10, 03/13/10, 03/14/10, 03/16/10, and 03/18/10.
RN #28 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/28/10.
RN #29 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/14/10 and 7 am - 7 pm shift on 03/06/10, 03/07/10, 03/24/10, and 03/27/10.
LVN #30 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/02/10, 03/04/10, 03/15/10, 03/19/10, 03/26/10, and 03/27/10.
RN #31 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/13/10.
RN #32 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/27/10.
RN #33 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/27/10.
RN #34 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/26/10.
LVN #35 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/18/10, 03/19/10, and 03/25/10.
LVN #36 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/05/10, 03/18/10, 03/19/10, and 03/21/10.
RN #37 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/07/10, 03/13/10, 03/15/10, and 03/17/10.
LVN #38 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/19/10.
RN #39 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/19/10.
LVN #40 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/05/10 and 7 am - 7 pm shift on 03/19/10.
LVN #41 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/10/10, 03/12/10, 03/16/10 and 03/17/10.
LVN #42 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/15/10 and 03/16/10.
LVN #43 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/13/10.
RN #44 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/12/10.
LVN #45 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/11/10.
LVN #46 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/08/10.
RN #47 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/01/10, 03/07/10, and 03/08/10.
LVN #48 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/07/10.
LVN #49 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/06/10.
LVN #50 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/05/10 and 03/06/10.
LVN #51 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/05/10 and 03/06/10.
LVN #52 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/02/10.
RN #53 worked the 7am - 7 pm shift on the Rehab 1 unit on 03/01/10.
LVN #54 worked the 7pm - 7 am shift on the Rehab 1 unit on 03/01/10.

In an interview with the COO (Personnel #2) on the afternoon of 04/29/10, she was asked how nonemployee nurses were oriented or evaluated. She stated there was currently no system in place for either orientation or evaluation.

Hospital policy " Orientation and Training " , dated 04/01/07 requires that " All nursing personnel will attend nursing orientation ... "

Findings:

Based on observation, review of records and interview, 1 of 1 nursing personnel (LVN #5) did not follow hospital policies and procedures while administering medications to a patient (Patient #9).

During a tour of Rehab Unit 1 at 8:30 am on 04/29/10, the surveyor observed LVN #5, in the hall preparing patient medications by opening 7 unknown pills from different pill packs into a clear plastic medication cup. The LVN did not verify the patient medications against a Medication Administration Record (MAR). The surveyor then followed the LVN to the Rehabilitation Department and observed the LVN walk up to Patient #9 and call his name and tell him it was time for his medication. The LVN handed the medication cup with the pills to Patient #9 without checking the patient ' s identification bracelet or medications against a MAR.

Medication Administration Record dated 04/29/10 for Patient #9, showed, Routine Medications due at 8:00 am were, Docusate 100 mg (stool softener), Metoprolol 100 mg (for hypertension), Lactobacillus 1 capsule, Levetiracetam 1000 mg (anti-epileptic drug), Phenytoin 200 mg (anti-epileptic drug), and Protonix 40 mg (for acid reflux).

Medication Management Policy, " Medication Administration " , dated 05/06/07, requires, " Prior to medication administration, the authorized staff member will ascertain positive patient identification. Two patient identifiers are required (name and date of birth) for this positive identification. The staff member will compare the patient ' s name and birth date on the armband to the patient ' s stated name and birth date, and to the name on the medication administration record (MAR). " It also requires, " The staff member administering the medication will verify that the medication selected for administration is the correct medication based on the medication order and the medication product label. "

In an interview with LVN #5, on the morning of 04/29/10, she was asked if she followed the hospital policies and procedures for medication administration to Patient #9. She stated, " No. "

Findings:
Based on review of records, and interviews, the nursing staff did not administer and monitor blood transfusions according to hospital policy and procedure, in that, 3 of 3 patients (Patients #1, #10, and #11) did not have vital signs monitored for transfusion reactions as required. In addition, the hospital failed to provide special training for blood transfusions in that 2 of 3 RN ' s (RN #47 and RN #59) that infused blood did not receive education and a competency assessment as required by hospital policy prior to infusing blood.

Nursing Policy, " Blood Products Administration Procedure " , dated 06/13/07, requires, " Vital signs are to be taken prior to the transfusion and noted on the appropriate area of the Blood Transfusion form ...Remain and observe the patient for 5-15 minutes for any sign of adverse reaction to the transfusion ...The vital signs MUST be taken at 15 minutes, 30 minutes, 1 hour and at the completion of the administration of each blood product ...When the infusion is complete, post transfusion vital signs must be taken and documented ...the blood transfusion form must be completed in its entirety during the course of the transfusion. " The policy also requires, " Nursing staff receive education and competency assessment prior to being assigned a patient requiring blood products. Should a nurse have a patient assigned whose condition requires blood products, the charge nurse will ensure that the staff nurse has completed their competency assessment and that the nurse has the confidence and support to safely administer the ordered products. "


1) Blood Transfusion forms for Patient # 1 received a blood transfusion on 03/01/10 and 03/02/10. On 03/01/10, RN # 47 failed to check vital signs after 30 minutes, 1 hour and at completion of administration of blood. On 03/02/10, RN # 58 failed to monitor the vital signs after 30 minutes and hourly during the transfusion. The nurse also failed to document if any signs or symptoms of transfusion reactions were noted.
2) Blood Transfusion forms for Patient #10 received two blood transfusions on 04/26/10. On blood transfusion #1, RN # 59 failed to check vital signs hourly and at the conclusion of unit 1. On the 2nd unit of transfused blood, RN # 59 failed to document vital signs pre-transfusion, 15 minutes, 30 minutes, hourly and at the conclusion of the transfusion. The nurse also failed to document if any signs or symptoms of transfusion reactions were noted.
3) Blood Transfusion forms for Patient # 11 received two blood transfusions on 02/23/10. RN # 60 failed to check pre-transfusion vital signs prior to infusion of unit 1 and unit 2.

Review of personnel and training files on the morning of 05/04/10, showed that RN ' s # 47 and # 59 did not receive the required special training and competency assessments prior to infusing blood or blood products.

In an interview with the COO, on the morning of 05/04/10, she was asked if RN ' s #47 and #59 received the required blood transfusion training and competencies. She stated, " No. "

In an interview with the RN House Supervisor (personnel # 4), on the morning of 05/04/10, she was asked to review the blood transfusion forms for Patient ' s # 1, 10 and 11. She was asked if the blood transfusion forms reflected that the blood administration was administered as per hospital policy and procedure. She stated, " No. "

Findings:

Based on observation, review of records and interview, 1 of 1 patients (Patient #1) was discharged home without changes in patient's condition or discharge needs having been addressed.

Patient #1's "Graphic Record" of vital signs showed a change in BP, HR and O2 Saturation prior to discharge.
On 03/04/10, the vital signs were: heart rate (HR) 66 beats per minute (bpm), blood pressure (BP) 138/70, and oxygen saturation 99%.
On the discharge date, 03/05/10, the HR increased to 96 bpm, the BP decreased to 93/54, and the oxygen saturation decreased to 96%.
"Nursing Shift Assessment" did not show that the RN identified nor addressed the change in the vital signs. The "Discharge Plan" dated 03/05/10 did not reflect any changes in the patient condition.

Complaint received by Texas Department of State Health Services received on 04/16/10 showed Patient #1 was discharged home from the facility on 03/05/10 at 11:00 am. She was taken by her family to another facility the same afternoon for fever and weakness. She was admitted through the Emergency Department for pneumonia.

Provision of Care Policy, " Discharge Criteria " dated 04/01/07, requires, " Patient ' s progress toward meeting functional goals will be continually monitored and assessed against the discharge criteria ...the patient experiences a major intervening surgical, medical, or psychological problem ... "

Provision of Care Policy, " Discharge Planning Process " , dated 04/01/07, states, " The purpose of the discharge planning process is to ensure that the gains achieved from hospital care are maintained or enhanced for the continued health and welfare ...the patient ' s needs are identified and evaluated and assistance given ...nurse will assess the patient ' s medical readiness for discharge ... "

Provision of Care Policy, " Discharge Planning Roles " , dated 04/01/07, requires, " The role of nurse in discharge planning ...identifies problems which potentially may have an adverse affect on assuring continuity of care ...consults with the physician regarding needs for discharge plan ...Administration ensures interdisciplinary involvement to promote safe and timely discharges to appropriate environments ... "