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Based on record review and interview, the hospital failed to ensure inpatient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by staff's failure to correctly identify grievances and complaints as per their hospital policy. This deficient practice had the potential to affect all inpatients during their stay at the hospital.

Findings:

Review of the hospital policy titled, Patient Complaint and Grievance policy, Policy number: II-U, date last reviewed: 9/16/14, revealed in part:
I. Purpose: To establish a process for timely referral, prompt review, investigation and resolution of patient complaints and grievances.
III. Definition of Terms: A. Complaint: Is a concern represented by a patient or patient's representative that can be addressed promptly by staff members who are present at the time of the complaint. "Staff Present" includes those individuals close to the complaint situation or who can quickly be at the patient's location. Generally, complaints can be resolved timely while the patient is still receiving care in the hospital.
B. Patient Grievance: Is a written or verbal complaint (when the verbal complaint about patient care is not resolved to the satisfaction of the patient or patient's representative 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 compliance with the CMS Conditions of Participation.
C. A written complaint is always considered a grievance, whether from in-patients, outpatients, released/discharged patient or their representative.
D. A verbal complaint: is a grievance if it cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further actions for resolution.

In an interview on 6/13/16 at 3:20 p.m. with S3RiskMgr she indicated patient complaints, handled while the patient was still in-house as an inpatient, even if requiring further investigation, were considered complaints and not grievances. She further indicated complaints handled in-house were not documented and no written response was sent to the complainants.

In an interview on 6/15/16 at 1:41 p.m. with S4RN, he indicated complaints received by the hospital that were that were resolved while a patient was still in-house, as an inpatient, were considered complaints, not grievances. He further indicated after " looking into " a complaint he would respond verbally to the complainant with his findings.

In an interview on 6/15/16 at 1:43 p.m. with S5RN, she indicated complaints received during a patient's stay, even if requiring additional research, that were resolved while the patient remained in-house were considered complaints. S5RN further indicated complaints the hospital received after patient discharge were considered grievances.

Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by administering Propofol continuous infusion without clarifying an incomplete physician's order for titration and administering a Nitroglycerin continuous infusion without clarifying an incomplete physician's order for 1 (#2) of 3 (#1,#2, #6) patients reviewed for continuous medication infusions out of a total of 6 sampled patients.

Findings:

Review of the hospital policy titled, Controlled Administration and Titration of IV Medication/Solutions and Admixtures, Policy Number: IV-G.2, last reviewed 4/13/15, revealed in part: I. Initiation, titration and monitoring of vasoactive, obstetrical, and cardioactive drugs will only be performed by registered nurses under the direction of a physician. III. Definition of terms: G. Titration: The process of increasing or decreasing the intravenous infusion rate by a vasoactive drug according to parameters specified by the physician. IV. General Information: A. Restrictions: 1. If there are no orders to " titrate " , the dosage shall not be changed without first notifying the physician. 4. These guidelines do not replace nursing judgment. The nurse is allowed to use his/her own judgment and monitor and document vital signs and titrate more frequently than listed.

Review of Patient #2's medical record revealed an admission date of 3/15/16 with an admission diagnosis of Peripheral Arterial Disease. Further review revealed the patient was coded on 3/18/16, was intubated and required ventilatory support.

Review of the patient's medical record revealed the following orders:

Start date: 3/18/16; 6:31 a.m.: Propofol 1000 mg (milligram)/100 ml (milliliter) Intravenous infusion; Titrate for sedation, starting dose 5 mcg (micrograms)/kg(kilograms)/min(minute), titration range: 5-50 mcg/kg/min. Maintain SAS (Riker Sedation-Agitation Scale) score of 3-4 with minimal hypotensive effect. Further review revealed no documentation of order clarification, by the nursing staff, for desired blood pressure parameters or specific time increments or specific dosages for titration.

Start date: 3/19/16; 3:31 a.m.: Nitroglycerin 25 mg/ Dextrose 5% in water D5W 250 ml Intravenously: Titration instructions: Start at 5 mcg/min. Titrate infusion every 3-5 minutes by increments of 5mcg/min until desired effect achieved. Further review revealed no documentation of order clarification, by the nursing staff, for description of the desired effect to be achieved or a specific time increment (without range) for titration.

In an interview on 6/14/16 at 12:40 p.m. with S3RiskMgr, she confirmed, after review of the above orders, that the orders contained ranges. She indicated the medication orders should have contained specific increments and time frames for titration of the medications. S3RiskMgr indicated it was the expectation of the hospital for nursing staff to call physicians to obtain clarification of orders containing ranges. She agreed failure to clarify the incomplete medication orders left choice of dose titration increments and time increments up to the interpretation of the nurse administering the medication.

In an interview on 6/15/16 at 1:41 p.m. with S4RN, he indicated it was the expectation of the hospital for nursing staff to call physicians to obtain clarification of continuous infusion medication orders containing ranges.