HospitalInspections.org

Based on medical record review, staff interview, and review of hospital policies, the facility's grievance log, and administrative documents, it was determined the hospital failed to ensure grievances were identified and promptly resolved for at least 1 of 15 patients (Patient #9) whose medical records were reviewed. This lack of identification resulted in the facility's failure to recognize a family's concerns as a grievance, prevented prompt resolution of grievances and had the potential to interfere with the rights of all patients in the facility. Findings include:

Patient #9's physician history and physical evaluation completed on 9/05/12, documented a 71 year old male who was admitted to the hospital on 9/04/12. The history and physical stated Patient #9 resided in a SNF prior to admission to the facility. It indicated he was admitted to the hospital for treatment related to verbal and physical aggression, anxiety, agitation and mental confusion. On 10/01/12, Patient #9 was discharged to a different SNF.

The facility's "Grievance Log" was reviewed. The log contained forms for 2012 and 2013. There were no documented grievances entered on the forms. Other administrative documents were provided along with the "Grievance Log". One of the documents was titled "Potential Patient Abuse Report Form." One of these forms, dated 9/24/12, was completed by the Director of Social Services. The form documented family concerns about Patient #9. The documentation included allegations made by Patient #9's family related to care and potential abuse. The form included documentation of an investigation of all allegations and patient, family and staff interviews. There was no evidence the allegations were entered as a grievance and results of the investigation provided to Patient #9 or his family.

The policy, "GRIEVANCE PROCEDURE," last revised 12/08, included "Any patient or family member expressing concern regarding any part of [name of the facility's] patient care procedures or practices is encouraged to complete a Grievance Form, available at the nurses' station or from any staff member. ...and a formal letter of acknowledging the concern and a plan or corrections will be mailed to the concerned party within 14 (fourteen) days."

The Director of Social Services was interviewed on 2/20/13, beginning at 9:00 AM. She reviewed Patient #9's record and confirmed the events discussed on the "Potential Patient Abuse Report Form" were not documented as a grievance. She also confirmed a copy of the investigation and/or written response of resolution was not provided to Patient #9 or his family.

The facility failed to identify a family's concerns about patient care and possible abuse as a grievance and did not provide a written response of resolution to the patient and family.

Based on medical record review, staff interview, and review of hospital policies, the facility's grievance log and administrative documents, it was determined the governing body failed to ensure the effective operation of the grievance process. This impacted 1 of 15 patients (#9) whose record was reviewed and had the potential to impact all patients who received care at the facility. This failed practice resulted in the lack of documentation of grievances and failed to establish resolution of the grievance process. Findings include:

Patient #9's physician history and physical evaluation completed on 9/05/12, documented a 71 year old male who was admitted to the hospital on 9/04/12. The history and physical stated Patient #9 resided in a SNF prior to admission to the facility. It indicated he was admitted to the hospital for treatment related to verbal and physical aggression, anxiety, agitation and mental confusion. On 10/01/12, Patient #9 was discharged to a different SNF.

The facility's "Grievance Log" was reviewed. The log contained forms for 2012 and 2013. There were no documented grievances entered on the forms. Other administrative documents were provided along with the "Grievance Log". One of the documents was titled "Potential Patient Abuse Report Form." One of these forms, dated 9/24/12, was completed by the Director of Social Services. The form documented family concerns about Patient #9. The documentation included allegations made by Patient #9's family related to care and potential abuse. The form included documentation of an investigation of all allegations and patient, family and staff interviews. There was no evidence the allegations were entered as a grievance.

"Governing Body Meeting Minutes" for 2012 were reviewed during the survey. Documentation that patient and/or family grievances were discussed was not present.

The grievance process was discussed with the Administrator on 3/22/13, beginning at approximately 12:45 PM. He confirmed patient and family concerns were not being identified as grievances and therefore, were not a topic of discussion in Governing Body meetings.

The governing body did not ensure a comprehensive and effective grievance process was utilized by the facility.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure restraints were utilized in accordance with orders of physicians or authorized LIPs. This affected the care of 1 of 2 patients (Patient #2) who were placed in restraints and whose records were reviewed. The use of restraints without proper authorization had the potential to result in the inappropriate use of restraints. Findings include:

Patient #2's Psychiatric Evaluation, dated 1/03/13, documented an 84 year old male who was admitted to the facility on 1/03/13. It stated Patient #2 was admitted for evaluation to rule out dementia. Patient #2's Discharge Summary, completed on 2/15/13, indicated Patient #2 was discharged from the facility on 2/14/13 and returned to an assisted living facility.

"NURSES NOTES," dated 1/28/13 at 8:30 PM, documented Patient #2 became increasingly agitated and aggressive toward staff. The note also indicated Patient #2 was unsteady on his feet. Documentation stated "Pt hitting and attempting to squeeze/crush staffs hands. CPI controlled position used at this time for pat and staff safety. Pt assisted in sitting position on bed in attempt to divert pt's attention into conversation. [Physician's name] notified 7:15 PM." The note said Patient #2 continued to exhibit agitation and aggressive behavior until 8:00 PM, when he was released from the CPI controlled position.

"DOCTOR'S ORDERS AND PROGRESS NOTES," dated 1/28/13, were reviewed. A physician progress note, dated 1/28/13 at 8:00 PM, described the events and the use of 2 staff members to "sit and restrain" Patient #2. However, there was no order for the CPI hold/physical restraint found in the record.

The DNS was interviewed on 3/20/13, beginning at 8:30 AM. She reviewed Patient #2's medical record and confirmed there was no order for CPI hold/physical restraint on 1/28/13.

Physical restraint was used for Patient #2 without a qualifying order from a physician or LIP.

Based on staff interview and review QAPI documents, it was determined the hospital failed to ensure its QAPI program analyzed and tracked relevant quality indicators. This resulted in a lack of feedback to staff which could prevent them from taking action to reduce adverse patient events. Findings include:

The hospital's QAPI program was reviewed. It maintained data by month on incidents and accidents including falls, skin tears, self-injury, bruises, patient to patient contact, and "other." However, the hospital did not use the data to identify trends or analyze increases in the number of incidents. For example, the "Summary of Incidents" presented to the Medical Executive Committee at their 12/04/12 meeting, documented numbers of incidents for the first 9 months of 2012. The number of falls stayed at or below 2 per month for 7 of those months. The number of falls climbed to 10 in May 2012 and 7 in July 2012. The number of patients with bruises was 4 for February of 2012, then remained at 3 or below until August 2012, and climbed to 11 for September 2012.

The Administrator was interviewed on 3/21/13 beginning at 10:15 AM. When asked if any causes for the rise in incidents had been identified for the affected months, he stated the QAPI program did not analyze causes for spikes in adverse patient events. He stated data was listed by month but staff did not look for trends in adverse patient events. In addition, he confirmed the QAPI program did not track restraint usage or all medication errors.

The hospital did not analyze and track adverse patient events in order to decrease their occurrence.

Based on staff interview and review of Idaho state rules for hospitals, it was determined the hospital failed to ensure there were an adequate number of pharmacists to ensure pharmaceutical services were provided to patients in accordance with accepted standards of practice. This resulted in the increased likelihood of drug interactions and medication errors. Findings include:

Idaho state licensing rules for hospitals (IDAPA 16.03.14.330.06.a) require that "The pharmacist shall review the prescriber's original order or a direct copy thereof." This provides the opportunity for the pharmacist to maintain a medication profile necessary for the review of drug interactions and medication errors.

The pharmacist was interviewed on 3/19/13 beginning at 11:20 AM. He stated he worked at the hospital for 8 hours on Tuesdays and for 4 hours on Fridays. He stated he did not review original medication orders or copies of those orders, either when he was at the hospital or when he was not at the hospital. He stated nurses transcribed the orders and entered them on to the MAR. He stated he updated patients' medication profiles, including checking for drug interactions when he was at the hospital but acknowledged it could be as long as 4 days before this happened. He stated the hospital did not have enough pharmacists to review medication orders and evaluate them for correct dosages, medication interactions, and other issues in a timely manner.

The hospital did not employ sufficient pharmacists to directly review medication orders.

Based on staff interview and review QAPI documents, it was determined the hospital failed to ensure its QAPI program measured and tracked quality indicators including adverse patient events in order to reduce medical errors. This prevented the hospital from analyzing categories of events in order to decrease their occurrence. Findings include:

The document "QAPI REPORT FOR THE YEAR OF 2012," not dated, listed the number of medical records that were audited in 2012 for medication errors, the number of doses of medication given to those patients whose records were audited, the number of medication errors, and the error percentage for those patients who were reviewed. Monthly reports included this same information.

"Medical Executive Committee Working Minutes," dated 12/04/12, included a report on the number of adverse patient events by month. The list included falls, skin tears, self injury, and others. The list did not include medication errors.

No other data on the number of medication errors was documented.

The pharmacist was interviewed on 3/19/13 beginning at 11:20 AM. He stated he reviewed a certain number of records each month and looked for medication errors and issues within those records. He stated he compiled statistics for those records. He stated the DNS tracked medication errors that were discovered and reported by nursing and other staff.

The DNS was interviewed on 3/21/13 beginning at 10:00 AM. She stated she did not track medication errors because the pharmacist tracked them.

The Administrator was interviewed on 3/21/13 beginning at 10:15 AM. He confirmed the number of medication errors was not tracked by the hospital's QAPI program.

The hospital did not track medication errors through its QAPI program. This prevented the hospital from accurately analyzing medication errors in order to prevent them.