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Based on record reviews, policy and procedure review and staff interviews, the hospital failed to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by: 1) failing to determine whether patient concerns were complaints or grievances for 2 (#6, R1) of 3 (#6, #7, R1) complaint/grievances reviewed; 2) failing to investigate patient grievances for 1 of 3 grievances reviewed (#6). Findings:

Review of the hospital policy titled, "Patient/Family Grievance", policy number I.A.4.0, revised 12/12 and provided by S1ADM (Administrator) as current policy, revealed in part the following: ....Patient Complaint - is defined as a patient or patient's representative expression of displeasure or dissatisfaction with service received, with a resolution being achieved at the time of the complaint. The complaint is considered resolved when the patient and/or representative are satisfied with the actions taken on their behalf.
Patient Grievance - formal written or informal written, fax, email, or verbal complaint that is made to the hospital (when the complaint is not resolved at the time of the complaint by staff present), by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with CMS requirements, or a Medicare beneficiary billing complaint.
"Staff Present" is defined as any hospital staff that is present at the time of complaint and can quickly be at the patients location to resolve the complaint. If a complaint cannot be resolved at the time of the complaint by "staff present", is postponed, requires referral to other staff for future resolution, requires investigation, and/or requires further action, the complaint will be considered a grievance....
Verbal complaints: Upon receiving a verbal complaint, the staff present receiving the complaint will immediately work to resolve the complaint to the acceptance of the patient or patient representative. A Grievance/Complaint Report form will be completed and forwarded to the Director of Quality/Risk Management.
Complaints will be referred to Quality/Risk Management in a timely manner, during working hours. Quality/Risk Management under the supervision of the Administrator will coordinate investigations or follow-ups and provide feedback to patient/patient representatives of resolution....
Procedure for Grievance: The Governing Board has delegated the responsibility of handling patient grievances to Administration and Risk Management who will respond, investigate, take appropriate action and communicate resolution, as appropriate, back to the patient or appropriate family member. Each issue defined as a grievance will be followed up with a written acknowledgement within 7-10 working day of receipt of the Grievance/Complaint Report form by the Administrator or designee....

Review of the "Patient Welcome Handbook" provided by S8RN Supervisor as current information provided to patients upon admission, revealed in part the following: Grievance Process: The following Grievance Process is part of our policy to promote Patient's Rights. If you have a complaint or concern, of any nature, please take the following steps: 1. Notify the RN Charge Nurse on duty. The nursing stations can be reached by dialing extension 2001....[Hospital] will implement the following measures when receiving a patient grievance: 1. All patient grievance (verbal or written) will be recorded on the patient Grievance/Concern Report and submitted to the Hospital Administrator for review within two (2) working days of occurrence. In the interim, our hospital staff will investigate the concern and provide you with feedback and resolution, if possible....

1) Failing to determine whether patient concerns were complaints or grievances:

Review of the Grievance/Complaint logs for November, December, 2012 and January 2013 revealed there were no complaints or grievances logged in November. Review of the December Log revealed 1 grievance and 1 complaint logged, both for Patient #R1. Review of the January Log revealed 1 grievance logged for Patient #7. There was no documented evidence of Patient #6 on the grievance/complaint logs.

Patient #6
Review of the patient's medical record revealed the patient was admitted to the hospital on 12/15/12 at 11:45 a.m. from Hospital A where she had bilateral total knee replacements on 12/12/12 for stabilization of Degenerative Joint Disease.

Review of the Incident Report for Patient #6 revealed the Incident Report was completed by S3RN Supervisor on 12/15/12 at 5:00 p.m. The incident report revealed the Severity level was, "Level 1-Minor", the nature of the event was, "Delay in Treatment", and the type of event was, "Irate or angry (either family or patient)". The Incident Report revealed there was no apparent physical effect. The patient was documented as alert and oriented and her functional level prior to the event was, "extensive assistance." The causative factor was checked for limited mobility/activity level. The documentation included S2DON and S14MD were notified at 5:00 p.m. The Overview of Incident was documented as follows: "Patient is new admit on Saturday , 12/15/12. Patient states she was left on bedpan in room and had accident (BM) (Bowel Movement). Further states it was 1 hour 45 minutes, 'nobody would help her'. Family with patient, very angry, upset. Patient crying, stating she wanted to go to Hospital B but came here instead. Dr. (S14MD) aware. Family states they are in contact with Hospital B currently. Supervisor aware. Hospital B contacted, left message with liaison." The section titled "Analysis and Prevention: what action has or will be taken to prevent recurrence?" was left blank.
There was no documented evidence of any attempt to address the patient's and the daughter's complaint.

Review of the Grievance/Complaint Report completed by S12Assistant ADM (Administrator) revealed the patient's complaint was received on 12/15/12 at 5:00 p.m. and revealed the following:
Describe in detail: Patient states she was left on bedpan in room and had an accident (BM). Further states, it was 1 hour 45 minutes and nobody would help her. Family in with patient, very angry and upset. Patient crying stating "she wanted to go to Hospital B, but came here instead." Family states they are in contact with Hospital B currently.
Actions taken by staff present to resolve issues: S14MD aware. Supervisor aware. Hospital B contacted, left message with liaison. After speaking with S14MD on Monday 12/17/12, the patient requested to go home. Patient was set up with home health....
Was grievance/concern resolved?: The answer was not marked.

Review of the Grievance/Complaint Risk Management Addendum completed by S12Assistant ADM revealed this form was to be utilized to document the receipt, research, and resolution of any complaint or grievance expressed by a patient or patient representative. Review of the form revealed the grievance/concern was received on 12/15/12 at 5:00 p.m. and was for Patient #6. The form revealed the patient grievance/concern was identified as a complaint and not a grievance. The section titled Documentation of Risk Management Follow-Up revealed the following: "Verified call light system working properly and all check out as working correctly. Patient chart reviewed. Patient discharged home with home health appropriately. Was grievance/concern resolved? N/A (Not applicable). Date resolved: 12/17/12."
There was no documented evidence that the patient complaint of being left on the bed pan and unable to get assistance was addressed or investigated.

In a face-to-face interview on 02/04/13 at 2:00 p.m., S12Assistant ADM verified she was responsible for reviewing all complaints/grievances and verified she had done the investigation of the complaint from Patient #6. S12Assistant ADM stated a complaint was something you can handle and correct on the spot and a grievance was something you needed to investigate or follow up. After reviewing the Grievance/Complaint documents for Patient #6, S12Assistant Administrator stated this complaint was initially handled as a complaint. She stated the reason it was determined to be a complaint was she looked at the record and the patient wanted to go home. S12Assistant ADM stated she did not talk to this patient. She stated the information regarding the complaint was obtained from the incident report. S12Assistant ADM stated she talked to S2DON about the incident, but did not speak to any of the staff involved in the complaint. S12Assistant ADM stated she did not remember what S2DON told her about the incident. S12 Assistant stated she would now file this as a grievance because it was not resolved at the time of the complaint. S12Assistant ADM further stated that after attending a CMS (Centers for Medicare & Medicaid Services) sponsored training, she would consider this complaint an allegation of neglect.


Patient #R1
Review of the Grievance/Complaint Report completed by S1ADM revealed the patient's representative's complaint was received on 12/19/12 at 1:30 p.m. and revealed the following:
Describe in detail: 1) 1 hour 15 minutes before being put to bed after admit. 2) Asked for Nicotine patch, was not ordered. 3) Loud music until 1 a.m. 4) Medications not correct.
Was a group meeting held? Yes; (identify all individuals in attendance and actions) No. "Yes" was documented in this section but there was no documentation of individuals attending the meeting or any actions taken.
What other action was taken to resolve the concern: 1) Nicotine patch ordered. 2) Review of meds with nurse practitioner and corrections made to include home medications as necessary. 3) Staff to be reprimanded for loud music. 4) Instruct charge nurse on rounding to get patient in bed timely.
Was grievance/concern resolved: Yes, describe resolution: See above.
Date patient or patient representative was notified in writing: Left blank.

In a face-to-face interview on 02/04/13 at 4:45 p.m., S1ADM verified she had done the investigation of the complaint received from Patient #R1. She stated she interviewed the patient and since it was resolved within 24 hours it was a complaint. After reviewing the Grievance/Complaint forms, she verified she had to talk to the staff, review the patient's medications, and talk to the nurse practitioner as part of her investigation. S1ADM verified the complaint was not resolved at the time of the complaint, but only after an investigation was conducted. S1ADM verified this patient complaint should have been handled as a grievance. After reviewing the Grievance/Complaint forms for Patient #6, she verified Patient #6's complaint should have been handled as a grievance.



2) Failing to investigate patient grievances:

Patient #6
Review of the patient's medical record revealed the patient was admitted to the hospital on 12/15/12 at 11:45 a.m. from Hospital A where she had bilateral total knee replacements on 12/12/12 for stabilization of Degenerative Joint Disease.

Review of the Incident Report for Patient #6 revealed the Incident Report was completed by S3RN Supervisor on 12/15/12 at 5:00 p.m. The incident report revealed the Severity level was, "Level 1-Minor", the nature of the event was, "Delay in Treatment", and the type of event was, "Irate or angry (either family or patient)". The Incident Report revealed there was no apparent physical effect. The patient was documented as alert and oriented and her functional level prior to the event was, "extensive assistance." The causative factor was checked for limited mobility/activity level. The documentation included S2DON and S14MD were notified at 5:00 p.m. The Overview of Incident was documented as follows: "Patient is new admit on Saturday , 12/15/12. Patient states she was left on bedpan in room and had accident (BM) (Bowel Movement). Further states it was 1 hour 45 minutes, 'nobody would help her'. Family with patient, very angry, upset. Patient crying, stating she wanted to go to Hospital B but came here instead. Dr. (S14MD) aware. Family states they are in contact with Hospital B currently. Supervisor aware. Hospital B contacted, left message with liaison." The section titled "Analysis and Prevention: what action has or will be taken to prevent recurrence?" was left blank.
There was no documented evidence of any attempt to address the patient's and the daughter's complaint.

In a face-to-face interview on 02/04/13 at 11:00 a.m., S3RN Supervisor stated he works every Saturday and Sunday and remembered Patient #6 was upset because she was left on the bedpan. S3RN Supervisor stated around 3:30 p.m. to 4 p.m. (Unable to provide specific time) family called on the call light and asked him to come to the patient's room to speak with the family. He stated he went to the patient's room, "4 O'clockish perhaps" and a family member complained about the incident and the length of time to get off the bedpan and they requested a transfer to Hospital B. S3RN Supervisor stated he documented the patient/family complaint on an incident report and verified he failed to document the time the incident occurred. S3RN Supervisor further stated a lot of times the charting is done "after the fact" and stated today is the first time he read the nursing documentation of the incident. When asked if he had taken any actions to determine if the patient was left on the bedpan for an hour and a half as reported by the patient's daughter, he stated no. He also verified he did not ask the staff what happened.

Review of the Grievance/Complaint Report completed by S12Assistant ADM (Administrator) revealed the patient's complaint was received on 12/15/12 at 5:00 p.m. and revealed the following:
Describe in detail: Patient states she was left on bedpan in room and had an accident (BM). Further states, it was 1 hour 45 minutes and nobody would help her. Family in with patient, very angry and upset. Patient crying stating "she wanted to go to Hospital B, but came here instead." Family states they are in contact with Hospital B currently.
Actions taken by staff present to resolve issues: S14MD aware. Supervisor aware. Hospital B contacted, left message with liaison. After speaking with S14MD on Monday 12/17/12, the patient requested to go home. Patient was set up with home health....
Was grievance/concern resolved?: The answer was not marked.

Review of the Grievance/Complaint Risk Management Addendum completed by S12Assistant ADM revealed this form was to be utilized to document the receipt, research, and resolution of any complaint or grievance expressed by a patient or patient representative. Review of the form revealed the grievance/concern was received on 12/15/12 at 5:00 p.m. and was for Patient #6. The form revealed the patient grievance/concern was identified as a complaint and not a grievance. The section titled Documentation of Risk Management Follow-Up revealed the following: "Verified call light system working properly and all check out as working correctly. Patient chart reviewed. Patient discharged home with home health appropriately. Was grievance/concern resolved? N/A (Not applicable). Date resolved: 12/17/12."
There was no documented evidence that the patient complaint of being left on the bed pan and unable to get assistance was addressed or investigated.

In a face-to-face interview on 02/04/13 at 2:00 p.m., S12Assistant ADM verified she was responsible for reviewing all complaints/grievances and verified she had done the investigation of the complaint from Patient #6. After reviewing the Grievance/Complaint documents for Patient #6, S12Assistant Administrator stated this complaint was initially handled as a complaint. She stated the reason it was determined to be a complaint was she looked at the record and the patient wanted to go home. S12Assistant ADM stated she did not talk to this patient. She stated the information regarding the complaint was obtained from the incident report. S12Assistant ADM stated she talked to S2DON about the incident, but did not speak to any of the staff involved in the complaint. S12Assistant ADM stated she did not remember what S2DON told her about the incident. S12 Assistant stated she would now file this as a grievance because it was not resolved at the time of the complaint. S12Assistant ADM verified there was no investigation done for the patient's complaint of being left on the bedpan for 1 hour and 45 minutes.

Based on policy and procedure review and staff interview, the hospital failed to ensure a system was in place to report allegations of abuse/neglect within 24 hours of the hospital becoming aware of the allegation in accordance with state law. Findings:

Review of the hospital policy titled, "Abuse of patients, Elder, Child, Staff Identification, Response and Reporting", Policy number I.A.1.0, revised date of 12/12, provided by S1ADM (Administrator) as current, revealed in part the following: Purpose:....Delineating procedures to be followed if abuse, neglect, mistreatment and/or exploitation is suspected to ensure that all information and possible evidentiary material(s) collected are safeguarded, that all applicable patient rights for consent are maintained, that all legally required reporting is performed, and that referrals are made as necessary and appropriate to private or public community agencies for victims of abuse....
Reporting/Response: All alleged violations and substantiated incidents shall be reported to the state and licensing agencies within 5 working days of the incident....

Review of LA R.S. 40.?2009.2 revealed:
Louisiana Revised Statutes Title 40. Public Health and Safety Chapter 11. State Department of Health and Hospitals ?2009.2. Definitions (Excerpt) (3) "Department" shall mean the Department of Health and Hospitals...?2009.20. Duty to make complaints; penalty; immunity. A. As used in this Section, the following terms shall mean: (1) "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. (2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home-and community-based service provider, employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. For the purposes of this Paragraph, the chief law enforcement agency of Orleans Parish shall be the New Orleans Police Department. (2) Any person who knowingly or willfully violates the provisions of this Section shall be fined not more than five hundred dollars or imprisoned for not more than two months, or both. C. Any person, other than the person alleged to be responsible for the abuse or neglect, reporting pursuant to this Section in good faith shall have immunity from any civil liability that otherwise might be incurred or imposed because of such report. Such immunity shall extend to participation in any judicial proceeding resulting from such report. D. All hospitals shall permanently display in a prominent location in their emergency rooms a copy of R.S. 40:2009.20.


Review of the Grievance/Complaint Report completed by S12Assistant ADM (Administrator) revealed a complaint from Patient #6 was received on 12/15/12 at 5:00 p.m. and revealed the patient complained of being left on the bedpan for 1 hour, 45 minutes and no one would help her. The complaint also revealed the patient and family were upset and angry and were requesting a transfer to another facility.

Review of the Grievance/Complaint Risk Management Addendum completed by S12Assistant ADM revealed this form was to be utilized to document the receipt, research, and resolution of any complaint or grievance expressed by a patient or patient representative. Review of the form revealed the grievance/concern was received on 12/15/12 at 5:00 p.m. and was for Patient #6. The form revealed the patient's grievance/concern was identified as a complaint and not a grievance. The section titled Documentation of Risk Management Follow-Up revealed the following: "Verified call light system working properly and all check out as working correctly. Patient chart reviewed. Patient discharged home with home health appropriately. Was grievance/concern resolved? N/A (Not applicable). Date resolved: 12/17/12."
There was no documented evidence that the patient complaint of being left on the bed pan and unable to get assistance was addressed or investigated.

In a face-to-face interview on 02/04/13 at 2:00 p.m., S12Assistant ADM verified she was responsible for reviewing all complaints/grievances and verified she had done the investigation of the complaint from Patient #6. After reviewing the Grievance/Complaint documents for Patient #6, S12Assistant Administrator stated she would now file this as a grievance because it was not resolved at the time of the complaint. S12Assistant ADM further stated that after attending a CMS (Centers for Medicare & Medicaid Services) sponsored training, she would consider this complaint an allegation of neglect. S12Assistant ADM stated she has learned that neglect should be reported to several agencies, and further stated she would have to look up information from the training to know who and when to report to.

In a face-to-face interview on 02/04/13 at 4:05 p.m., S2DON (Director of Nursing) verified she was notified on 12/15/12 that Patient #6 was upset about being left on the bedpan and wanted to transfer to another hospital. S2DON stated if the patient was left on the bedpan for 1 hour and 45 minutes, she would consider that neglect. S2DON stated she thought allegations of neglect had to be reported to DHH (Department of Health & Hospitals), but she was not sure of the time frame for reporting. After reviewing the the hospital's policy and training on abuse/neglect provided to hospital staff, she verified the training and the policy indicated allegations of abuse should be reported within 5 days. S2DON stated approximately 70% of the staff were trained on this policy.

In a face-to-face interview on 02/04/13 at 4:45 p.m., S1ADM (Administrator) verified the hospital's policy, "Abuse of Patients, Elder, Child, Staff Identification, Responses and Reporting" was the training that was provided to the staff on abuse/neglect, and was the current hospital policy. S1ADM verified the time frame for reporting to the state and licensing authorities in the policy was within 5 days. After reviewing the Grievance/Complaint forms for Patient #6 dated 12/15/12, S1ADM verified the patient's complaint should have been handled as a grievance. When asked if the patient's complaint of being left on a bedpan for an hour and 45 minutes could be considered neglect, she stated yes, and asked if she should report this to the state now.

Based on record review and interviews the hospital failed to have a procedure in place to ensure that hospital nursing personnel for whom current licensure was required had verification of a valid and current license for 3 (S5LPN, S18LPN, S19LPN) of 6(S3RNSupervisor, S5LPN,S7RNSupervisor, S8RNSupervisor, S18LPN, S19LPN) nursing personnel files reviewed.
Findings:

Review of hospital policy # I.B.7.0 (Revised 12/12, Approval date 12/12, and effective date 12/12) titled License Verification, and provided by S1ADM (Administrator) 2/4/13 at 5:05 p.m. as current revealed, in part, that the policy was to ensure that all personnel of whom licensure was required were valid and current. The procedure was that the HR (Human Resource) Director would view and document dates viewed and file such documentation in the employee file. This would be done annually. The procedure also stated that, "No nursing or contract personnel will be allowed to work in any capacity without a current license being presented on or before expiration date."
It was noted that the state of Louisiana prohibited the copying of any license for RNs (Registered Nurses) and LPNs (Licensed Practice Nurses) unless it was defaced.

Review of personnel files for S5LPN (Licensed Practical Nurse), S18LPN, and S19LPN revealed a documented license verification of a license expiration date of 1/31/13. Further review revealed no documented verification of a current valid license.

In a face to face interview 2/4/13 at 12:05 p.m. S6HRManager (Human Resource Manager) verified that S5LPN, S18LPN, and S19LPN had no verification of a current and valid nursing license in their respective personnel files. S6HR Manager stated that license verification of LPNs had to be done through a letter to the Louisiana State Board of Practical Nurse Examiners requesting verification of a current and valid license. She said that since the LPN licenses expired 1/31/13, the hospital waited until the end of January to verify those licenses. She reported that she had a letter dated 1/31/13 that had been sent, requesting verification of all staff LPN licenses, and provided a letter addressed to the licensing board requesting verification of the 33 LPNs listed on an attachment. She verified that the list included all LPNs actively employed by the hospital. Attached was an envelope addressed to the State Board . When asked if the letter had been sent yet, S6HRManager said that it had been sent to the corporate office that morning for a signature on a check to be included since there was a fee for the verifications, but it had not been sent to the Board of Practical Nurse Examiners. Attached to the letter was a list of 33 names of hospital employed LPNs ( which included their individual license numbers). The director verified that the licensed verification had not yet been sent to the Board of Practical Nurse Examiners, therefore the hospital did not have verification of a current and valid license for any of the staff LPNs that were scheduled and working since 2/1/13. The HR Director was not sure what the hospital's policy and procedure was for verification of licensure of employees, only that she knew it had to be done upon hire and then annually.

In a face to face interview on 2/4/13 at 4:25 p.m., S2DON (Director of Nursing) reported that she was not involved in nursing license verification. She stated that she was not aware that hospital LPNs were currently working without verification of a current license.

In a face to face interview on 2/4/13 at 5:05 p.m., S1ADM (Administrator) reviewed the list of LPNs for which a current and valid nursing license was going to be requested. She confirmed that at the present time, the 33 LPNs on staff had not had their current licenses verified. S1ADM also said several of the LPN's without verification of a current license had worked since 2/1/13 and others were scheduled to work.

Based on record review and staff interview, the Registered Nurse (RN) failed to supervise and evaluate the nursing care for each patient as evidenced by: a) failing to ensure the patient received assistance with toileting resulting in the patient being left on the bedpan for 40 minutes, and the patient being soiled with urine and feces; b) failing to assess the patient's skin condition after the patient complained of being left in urine and feces for 1 hour and 45 minutes; c) failing to respond to the patient's complaint in a timely manner for 1 (#6) of 2 (#6, #7) sampled patients reviewed for complaints out of a total sample of 10. Findings:

Review of the hospital policy titled "Admission Assessment", policy number I.G.3.0, approved/revised/reviewed date of 04/12, provided by S1ADM (Administrator) as current policy for Nursing Assessments, revealed in part the following: ....C. Reassessment is based on continued desire for care, response to care and change in patient status. Each patient is reassessed at regularly specified time related to the patient's course of treatment, to determine the patient's response to treatment, when a significant change occurs in the patient's condition and when a significant change occurs in the patient's diagnosis.

Review of the hospital policy titled, "Patient/Family Grievance", policy number I.A.4.0, revised 12/12 and provided by S1ADM as current policy, revealed in part the following: ....Patient Grievance - formal written or informal written, fax, email, or verbal complaint that is made to the hospital (when the complaint is not resolved at the time of the complaint by staff present), by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital;s compliance with CMS requirements, or a Medicare beneficiary billing complaint. "Staff Present" is defined as any hospital staff that is present at the time of complaint and can quickly be at the patients location to resolve the complaint. If a complaint cannot be resolved at the time of the complaint by "staff present", is postponed, requires referral to other staff for future resolution, requires investigation, and/or requires further action, the complaint will be considered a grievance.... Verbal complaints: Upon receiving a verbal complaint, the staff present receiving the complaint will immediately work to resolve the complaint to the acceptance of the patient or patient representative. A Grievance/Complaint Report form will be completed and forwarded to the Director of Quality/Risk Management....

Review of the "Patient Welcome Handbook" provided by S8RN Supervisor as current information provided to patients upon admission, revealed in part the following: Grievance Process: The following Grievance Process is part of our policy to promote Patient's Rights. If you have a complaint or concern, of any nature, please take the following steps: 1. Notify the RN Charge Nurse on duty. The nursing stations can be reached by dialing extension 2001....Sage will implement the following measures when receiving a patient grievance: 1. All patient grievance (verbal or written) will be recorded on the patient Grievance/Concern Report and submitted to the Hospital Administrator for review within two (2) working days of occurrence. In the interim, our hospital staff will investigate the concern and provide you with feedback and resolution, if possible....

Patient #6
Review of the patient's medical record revealed the patient was admitted to the hospital on 12/15/12 at 11:45 a.m. from Hospital A where she had bilateral total knee replacements on 12/12/12 for stabilization of Degenerative Joint Disease. The record revealed the patient's diagnoses also included Obesity, Anemia, Hypothyroidism, Hiatal Hernia, Gastro-Esophageal Reflux Disease, Neuropathy of hand and feet, Pain Control, Gastroparesis and Depression/Anxiety.

Review of the nurse's notes revealed the following:
12/15/12 at 1:50 p.m. "Patient called for bedpan, assisted per tech (Nurse Technician), call bell in hand and instructed on use and verbalized understanding." This entry was signed by S5LPN (Licensed Practical Nurse).
12/15/12 at 2:30 p.m. "Called to room per ward clerk, patient upset, bedpan beside patient with feces on sheet and gown, patient and patient's daughter angry, patient crying, daughter saying patient was left for 1 hour and 45 minutes in feces. Tech asked patient if she called for assistance, daughter states it doesn't matter this is unacceptable. Patient cleaned, bed bath given, gown changed." This entry was signed by S5LPN
12/15/12 at 4:30 p.m. "Assisted to BSC (Bedside Commode) per patient's request. She insisted on using her BSC from home. Very upset & states she's had a 'bad day, she was left in feces X (for) 2 hours.' Husband at bedside." This entry was signed by S7RN Supervisor.

There was no documented evidence of an assessment of the patient's skin condition and there was no documented evidence of any attempt to address or resolve the patient's and the daughter's complaint.

Review of the Incident Report for Patient #6 revealed the Incident Report was completed by S3RN Supervisor on 12/15/12 at 5:00 p.m. The incident report revealed the Severity level was, "Level 1-Minor", the nature of the event was, "Delay in Treatment", and the type of event was, "Irate or angry (either family or patient)". The Incident Report revealed there was no apparent physical effect. The patient was documented as alert and oriented and her functional level prior to the event was, "extensive assistance." The causative factor was checked for limited mobility/activity level. The documentation included S2DON and S14MD were notified at 5:00 p.m. The Overview of Incident was documented as follows: "Patient is new admit on Saturday, 12/15/12. Patient states she was left on bedpan in room and had accident (BM) (Bowel Movement). Further states it was 1 hour 45 minutes, 'nobody would help her'. Family with patient, very angry, upset. Patient crying, stating she wanted to go to Hospital B but came here instead. Dr. (S14MD) aware. Family states they are in contact with Hospital B currently. Supervisor aware. Hospital B contacted, left message with liaison." The section titled "Analysis and Prevention: what action has or will be taken to prevent recurrence?" was left blank.
There was no documented evidence of any attempt to address the patient's and the daughter's complaint.

Review of the Grievance/Complaint Report completed by S12 Assistant ADM (Administrator) revealed the patient's complaint was received on 12/15/12 at 5:00 p.m. and revealed the following:
Describe in detail: Patient states she was left on bedpan in room and had an accident (BM). Further states, it was 1 hour 45 minutes and nobody would help her. Family in with patient, very angry and upset. Patient crying stating "she wanted to go to Hospital B, but came here instead." Family states they are in contact with Hospital B currently.
Actions taken by staff present to resolve issues: S14MD aware. Supervisor aware. Hospital B contacted, left message with liaison. After speaking with S14MD on Monday 12/17/12, the patient requested to go home. Patient was set up with home health....
Was grievance/concern resolved?: The answer was not marked.
There was no documented evidence that the staff present at the time of the complaint/grievance took any actions to resolve the patient's complaint regarding being left on the bedpan and unable to get assistance.

In a face-to-face interview on 02/03/13 at 2:12 p.m., S7RN Supervisor stated she was working on Saturday, 12/15/12 and thought S3RN Supervisor was assigned to the Rehab unit that day since he admitted Patient #6. S7RN Supervisor stated she had to go in the patient's room because they said she was upset. She stated she could not remember who told her the patient had a complaint. She stated when she went into the patient's room, the patient was crying and said she was left on the bedpan. S7RN Supervisor stated she told the patient to ask to speak to the charge nurse if it happened again. S7RN Supervisor stated they (S7RN Supervisor & S5LPN) discussed the time frame the patient was on the bedpan on Sunday (12/16/12) and figured it was not as long as she said. S7RN Supervisor stated the other issue involved was no one turned the call light on. She stated the patient's daughter came and got S5LPN. After reviewing the nurse's notes documented at 2:30 p.m., S7RN supervisor stated, "Maybe she did use the call light." S7RN Supervisor verified she made an entry into the nurse's notes on 12/15/12 at 4:30 p.m. and the patient was still upset about being left in feces.

In a face-to-face interview on 02/04/13 at 9:50 a.m., S5LPN verified she was assigned to Patient #6 on 12/15/12 and recalled the patient's complaint regarding being left on the bedpan and unable to get assistance. S5LPN stated the patient had "something wrong with her stomach and could not control her bowels". S5LPN stated she had instructed the nurse tech to put the patient on the bedpan due to her mental status. S5LPN stated the patient used the call light to call for assistance, but at 2:30 p.m. the patient's daughter went to the nurse's station and complained to the ward clerk that the patient was soiled. S5LPN stated the ward clerk told her (S5LPN) to go to the patient's room and see what the patient's daughter was upset about. S5LPN stated when she arrived in the room, the patient was in bed, the bedpan was beside her in the bed and the patient was soiled with urine and feces. S5LPN stated S4NT (Nurse Technician) was present and asked the patient if she had called for assistance. S5LPN stated the patient's daughter was mad and stated this was unacceptable. S5LPN stated she then bathed the patient and changed the bed linens. S5LPN stated she reported the patient's complaint to S7RN Supervisor and S3RN Supervisor and she did not know what was done after that. After reviewing her documentation in the nurse's notes, S5LPN stated that the entry made at 1:50 p.m. was information reported to her by S4NT and not witnessed by her (S5LPN). When asked if staff are to check on a patient after a patient was put on the bedpan, she stated the patient had the call bell in her hand and she could call. S5LPN stated she would expect the nurse tech to check on a patient within 20 minutes of placing a patient on a bedpan. S5LPN verified she did not document an assessment of the patient's skin and she had not taken any actions to address the patient's and the daughter's complaint.

In a face-to-face interview on 02/04/13 at 10:25 a.m., S4NT verified she was assigned to Patient #6 on 12/15/12 and recalled the patient's complaint. S4NT stated Patient #6 refused to use the call light. S4NT stated she was making her rounds and went into the patient's room and the patient told her she needed to use the bathroom. S4NT stated she asked the patient how she wanted to use the bathroom and the patient told her she did not want to go to the bathroom. S4NT stated she offered the bedpan and the patient agreed. S4NT stated she then assisted the patient onto the bedpan and placed the call light next to her, instructed the patient to call, and the patient said ok. S4NT stated she then went on break. S4NT stated when she returned from her break, she heard loud screaming coming from the patient's room. S4NT stated she and S5LPN ran into the room. S4NT stated the patient's daughter was present and the patient had BM (Bowel movement) on her gown, the sheets, and her hands. S4NT stated she did not remember where the bedpan was and does not remember removing the bed pan. S4NT stated she had been instructed by the hospital to check patients on bedpans within 3-5 minutes. When asked if anyone checked on Patient #6 in 3-5 minutes, she stated she thought S3RN Supervisor checked on the patient. S4NT was unable to identify the staff member she reported to when she went on break after placing Patient #6 on the bedpan.

In a face-to-face interview on 02/04/13 at 11:00 a.m., S3RN Supervisor stated he works every Saturday and Sunday and remembered Patient #6 was upset because she was left on the bedpan. S3RN Supervisor stated he went into the patient's room to answer the call light and stated he was not sure of the time, but thought it was, "late afternoon". He stated when he went into the patient's room, the patient was alone and he "understood she was still on the bedpan and she was crying and upset at being left on the bedpan and no one came to help her." S3RN Supervisor stated he asked if she would like a female to assist her and she said yes. He stated his observation was the patient was not soiled at this time. He stated he went to the hall and told S5LPN and the tech (did not remember which tech) the patient was ready to get off the bedpan. S3RN Supervisor stated the patient complained she was left on the bedpan 1 and a half hours. S3RN Supervisor stated the LPN and tech went into the room and assisted the patient with her ADLs and also stated there was no family present at that time. S3RN Supervisor stated around 3:30 p.m. to 4 p.m. (Unable to provide specific time) family called on the call light and asked him to come to the patient's room to speak with the family. He stated he went to the patient's room, "4 O'clockish perhaps" and a family member complained about the incident and the length of time to get off the bedpan and they requested a transfer to Hospital B. S3RN Supervisor stated he documented the patient/family complaint on an incident report and verified he failed to document the time the incident occurred. S3RN Supervisor further stated a lot of times the charting is done "after the fact" and stated today is the first time he read the nursing documentation of the incident. When asked if he had taken any actions to determine if the patient was left on the bedpan for an hour and a half as reported by the patient's daughter, he stated no. He also verified he did not ask the staff what happened. S3RN Supervisor verified he did not document any of his actions in the nurse's notes and verified he did not assess the patient's skin condition after informed of the patient/daughter's complaint. S3RN Supervisor stated he did not recall the nurse tech reporting she was taking a break and the patient was on the bedpan.

Based on interview and record review, the hospital failed to ensure the nursing staff developed comprehensive individualized nursing care plans for 9 (#1, #3, #4, #5, #6, #7, #8, #9, #10) of 10 (#1-#10) patients sampled.
Findings:
Review of the hospital policy titled Patient Care Plan/Treatment Plan, Policy Number: I.G.12.0, Revised 12/12 revealed in part:
Policy: ...The plan of care should be goal oriented, patient specific, and updated to meet patient's needs ...
Purpose: ...To provide a guide for administering care since the plan describes what nursing care is to be provided and what measures will be implemented.
4) ...The plan will reflect the patient's current condition and needs and will be modified, as appropriate, to meet the changing needs of the patient.
G. How to use Nursing Care Plan
1) Use the entire plan when making assignments.
2) Use the care plan as a guide in supervising and evaluating the patient's care.
3) Use the care plan to coordinate the plan as well as monitor the patient's progress.

Patient # 1
Review of a consultation for Patient #1 dated 1/30/13 by S13 Physician revealed he had been admitted to the hospital on 1/29/13 with the chief complaint of a fall with a hip fracture. Further review revealed Patient #1's medical problems included a history of deep vein thrombosis (blood clot) being treated with Coumadin (blood thinner). Patient #1's diagnoses also included a chronic left foot ulcer, Barrett's esophagus (disorder in which lining of the esophagus is damaged by stomach acid), and Depression.
Review of the Interdisciplinary Plans of Care for Patient #1 revealed no care plans had been initiated for his deep vein thrombosis, left foot ulcer, Barrett's esophagus, or Depression.
In an interview on 2/3/13 at 2:20 p.m. with S8RN Supervisor, she stated the nursing staff mostly initiated care plans for the patients top rehabilitation problems and had been overlooking the other medical problems of the patients when initiating care plans. S8 RN Supervisor stated while the patients were in the hospital, they should have all of their medical problems addressed. She also said she could agree the lack of care planning for medical issues other than rehabilitation related issues was a problem.

Patient # 8
Review of the History and Physical for Patient #8 dated 1/20/13 revealed she had been admitted to the hospital on 1/19/13 with the etiologic diagnosis of right ankle pain with non-weight bearing status. Further review revealed Patient #8 was admitted with other medical problems which included Diabetes mellitus type II, UTI (Urinary Tract Infection), Hypertension (High Blood Pressure), Dementia, and acute renal failure.
Review of the Interdisciplinary Plans of Care for Patient #8 revealed no care plans had been initiated for her Diabetes, UTI, Hypertension, Dementia, or acute renal failure. These findings were verified by S8RN Supervisor on 2/3/13 at 2:20 p.m.

Patient #9
Review of the History and Physical for Patient #9 dated 1/31/13 at 1830 revealed she had been admitted to the hospital with the diagnosis of osteoarthritis. Review of the Physician's Orders for Patient #9 dated 2/2/13 at 0600 revealed an order to apply Optifoam to Stage II decubitus ulcers on the left and right coccyx.
Review of the Interdisciplinary Plans of Care for Patient #9 revealed no care plans had been initiated for the decubitus ulcers on her left and right coccyx.
In an interview on 2/4/13 at 4:45 p.m. with S1 Administrator, she verified the staff had not been initiating Interdisciplinary Plans of Care for medical problems unrelated to physical rehabilitation.


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Patient #3:
Review of the medical record for Patient #3 revealed he was admitted to the hospital from an acute care hospital on 1/19/13 with diagnoses that included Status post respiratory failure, with continued chest congestion, COPD (Chronic Obstructive Pulmonary Disease), Obstructive sleep apnea, Morbid obesity, Diabetes Mellitus (DM), Hypertension, and Hyperlipidemia. The physician's consultation noted that the patient was very debilitated. Further review of a History and Physical revealed that the patient had also been diagnosed with Coronary artery disease with stents placed, Asbestosis, Left knee osteoarthritis with knee replacement, dysphasia (difficulty swallowing), and Pneumonia, and the patient was a smoker. Patient # 3's allergies were listed as Erythromycin (antibiotic), fish, and Iodine.

Review of Interdisciplinary Plans of Care for Patient #3 revealed no care plans had been initiated that addressed the patient's Obstructive sleep apnea, his Diabetes, Hypertension, Dietary and Nutritional needs, or his allergies. Further review revealed a plan of care titled Knowledge deficit related to "new admit". The plan of care listed who should be included and techniques for patient education, but did not address what education was to be provided for Patient #3.

Patient # 4:
Review of the medical record for Patient #4 revealed she was a 69 year old female admitted to the hospital from an acute care hospital after a fall at home, surgery on her back, then continued leg pain and a decline in her strength as well as Neurogenic bladder symptoms. Patient #4's admitting diagnoses included Incomplete paraparesis (partial paralysis of the lower limbs) secondary to thoracic myelopathy (a functional disturbance and/or pathological change in the spinal cord), Osteomyelitis (an infection in bone)- on antibiotics, Neurogenic bowel and bladder, Hypertension, History of Myocardial Infarction, Impaired ADLs (activities of daily living), Impaired functional mobility, Impaired ambulatory skills, High fall risk, and Postop pain. The physician's consultation listed past medical history to include, in part, COPD, Osteoarthritis of the knees, Bilateral Cataracts, History of Pneumonia, and Previous lumbar surgery. Her allergies were listed as Morphine.

Review of Interdisciplinary Plans of Care for Patient #4 revealed no care plans were initiated that addressed Patient #4's skin integrity (medical record documented staples in surgical incision site to back, and decreased mobility) or needs related to her diagnoses of COPD. Further review revealed that a care plan titled Knowledge Deficit related to new admit was checked to institute all of the interventions listed on the preprinted care plan, but did not address what subject teaching was needed or planned for Patient #4.


Patient #5:

Review of the medical record for Patient #5 revealed that she was a 70 year old female admitted to the hospital 1/25/13 for rehabilitation following bilateral knee replacements at the end of January, 2013. Her diagnoses included, in part, Rheumatoid arthritis, COPD, History of DVT (deep vein thrombosis), Insomnia, Seizure disorder, Osteoarthritis of the knees, some eye surgery (not specified), and status post craniotomy in 1978 from a gunshot wound to the head.

Review of Interdisciplinary Plans of Care for Patient #5 revealed no care plans initiated that addressed Patient #5's needs for seizure precautions, her COPD, her history of DVT, including the prophylactic medication prescribed for her, or her Insomnia.


Patient #7:

Review of the medical records for Patient #7 revealed that he was a 75 year old male admitted to the hospital 1/25/13 for inpatient rehabilitation following an episode of syncope, that resulted in a fall at his home. He was admitted from a local acute care facility where he was diagnosed with Atrial Fibrillation, Rapid Ventricular Response, and fractures to his right radius and right seventh rib. His diagnoses also included Debilitation, Anorexia, malnutrition, significant weight loss, and history of H. pylori (a bacterium found in the stomach), Alcoholic polyneuropathy, history of acute renal insufficiency, and CHF (Congestive Heart Failure). The patient was discharged to home 1/30/13 with home health ordered.

Review of Interdisciplinary Plans of Care for Patient #7 revealed no care plans initiated that addressed his care needs, including education, for Anorexia or his dietary and nutritional needs. The plans of care for Patient # 7 included Constipation related to "Above", Impaired Mobility related to "_____", Activity Intolerance related to" ______", Potential for Injury related to safety risk, Pain related to" _____", Fluid Volume Excess related to"_______", and Decreased Cardiac Output related to"_______". The blank spaces in the care plans were left blank and did not individualize the plan of care. A care plan for constipation had the word "ABOVE" written into the blank space. There was nothing written above (or elsewhere) on the page that would explain the word "above". All plans of care had either checks or Xs to mark the preprinted interventions. There were no notes on the plans of care that individualized the reason for the care plan, the interventions, the goals, or any revisions.


Patient #10:

Review of the medical record for Patient #10 revealed she was a 65 year old female admitted 1/25/13 from an acute care hospital for inpatient occupational, speech, and physical therapy. According to a History and Physical dated 1/29/13 Patient #10 was admitted with the following impressions: Toxic polyneuropathy secondary to alcohol abuse, History of encephalopathy secondary to alcohol abuse, Hypertension, Atrial fibrillation, Erosive esophagitis, History of Myocardial Infarction, Dysphagia status post PEG (Percutaneous Endoscopic Gastrostomy) tube, Dysarthria (difficulty in speech), Impaired gait, Impaired Functional Ability, Impaired Safety, High Fall Risk, Impaired balance with decreased coordination. Her allergies listed were dairy and sulfa. Under recommendations, the History and Physical noted, in part, E/M (expected management) for medical situations requiring immediate attention such as DVT, PE (Pulmonary Embolus), pressure decubiti, infections, bleeding, and/or falls. The recommendations stated that the "patient does demonstrate the need for interdisciplinary team for the active management of the following medical and functional deficits: ataxia (loss of the ability to coordinate muscular movement), ...cognition, precautions, safety, skin care, wound management, swallowing, and transfers."

Review of physician's orders revealed, in part, the following:
1/25/13 at 1:30 p.m.: Mechanical soft, thin liquid diet in day and Glucerna 1.5 at 50 ml (milliliters) HS (at bedtime) from 7:00 p.m. to 7:00 a.m., continuous.
1/25/13 at 9:00 p.m.: One to one feeding.
1/26/13 at 4:30 p.m.: Change diet to mechanical soft diet with finely chopped meat (gravy on meat) and nectar-thick liquids and Glucerna 1.5 at 50 ml. at night. No straws.
2/2/13 at 9:30 a.m.: Xanax 0.25 mg (milligrams) p.o. (by mouth) now and every 6 hours prn (as needed) for anxiety, agitation.

Review of Interdisciplinary Plans of Care for Patient #10 revealed no care plans that addressed patient needs or problems concerning a PEG tube, nutritional needs, skin integrity, anxiety, or Dysphagia.



17091

Patient #6
Review of the patient's medical record revealed the patient was admitted to the hospital on 12/15/12 at 11:45 a.m. from Hospital A where she had bilateral total knee replacements on 12/12/12 for stabilization of Degenerative Joint Disease. The record revealed the patient's diagnoses also included Obesity, Anemia, Hypothyroidism, Hiatal Hernia, Gastro-Esophageal Reflux Disease, Neuropathy of hand and feet, Pain Control, Gastroparesis and Depression/Anxiety.

Review of the Interdisciplinary Plans of Care for Patient #6 revealed no care plans had been initiated for her Depression/Anxiety, Gastro-Esophageal Reflux Disease, Anemia, Hypothyroidism, Hiatal Hernia, Neuropathy, or Gastroparesis. Further review of the patient's plan of care revealed the problem identified as "Pain related to surgery", had no identified interventions. The problem identified as "Potential for injury related safety risk" revealed the only intervention identified was assess for risk factors. The problem identified as "Impaired skin integrity related to surgery" revealed the only identified intervention was to identify patients at high risk by use of Braden Scale on admission and every 5 days. The problem identified as "Self-care deficit related to pain, surgery" revealed the only identified intervention was to assess the patient's ability to perform self-care activities and need for assistive devices on admission and as needed.
In a face-to-face interview on 02/04/13 at 11:00 a.m., S3RN Supervisor verified he had admitted Patient #6 on 12/15/12 and had initiated the plan of care. S3RN Supervisor stated he used the Pre-Admission Screening as basis for initiating the plan of care since the physician has not yet evaluated the patient. S3RN Supervisor verified the patient's medical diagnoses were not included in the plan of care, but were on the Pre-Admission Screening form. S3RN Supervisor verified the plan of care was not completed properly and did not include interventions for the above identified problems.
In a face-to-face interview of 02/04/13 at 4:05 p.m. S2DON (Director of Nursing) reviewed the plan of care for Patient #6 and verified the patient's medical problems were not addressed on the plan of care. S2DON also verified there were no interventions identified for the patient's problems as indicated above.