HospitalInspections.org

Based on review of records and interviews with hospital staff, the hospital does not ensure the hospital protects and promotes the rights of patients.

Findings:

1. The hospital failed to establish a grievance process that ensures grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care. Refer to Tag A- 118

2. The hospital failed to establish a grievance process that specifies the time frames for a review of the grievance and a response to the grievance. Refer to Tag A-122.

3. The hospital failed to ensure all complaints/grievances requiring investigations and are not immediately resolved are treated as a grievance and receive a written response containing the steps taken in the investigation, the results of the grievance process, and the date of completion. Refer to Tag A-123.

4. The hospital failed to ensure patients receive care in a safe setting. Refer to Tag A-144

5. The hospital does not have mechanisms/methods defined in its policies that describe the procedure to follow when a patient alleges abuse by a hospital employee or worker and includes all the components necessary for effective abuse protection. Refer to Tag A-145

Based on review of hospital documents and interviews with staff, the hospital failed to establish a grievance process that ensures grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care.

Findings:

1. On the morning of 6/20/2011 surveyors reviewed the grievance log. Two grievances were listed in the log for 2011. Staff A told surveyors grievances were reviewed by Staff C and the appropriate department manager. Documentation of grievance resolution was handled by the case manager.

2. Review of Quality meeting minutes for 2011 did not contain evidence grievances were incorporated into the QAPI program. On the morning of 6/20/2011, Staff A stated grievances went to staff C and at times to Staff F. There was no evidence all grievances were reviewed through Quality Meetings and Governing Body.

3. The documentation did not show the results of the investigations of the grievances had been analyzed with processes for improving problem areas.

Based on review of the hospital's grievance/complaint policy, grievance log and four grievances and interviews with hospital staff, the hospital failed to identify grievances, establish time frames for resolution, and provide patients with information on all components of the grievance process. This occurred for four of four grievances (Grievance #1 through 4) reviewed.

Findings:

1. The hospital "admitting packet" states in item #17 " You are encouraged throughout your stay in the Specialty Hospital, to understand and exercise your rights as a patient and citizen. You may voice grievances and recommend changes in policies and services to a member of the Specialty Hospital staff or others, free from restraint, intereference, coercion, discriminatin or reprisal, including threat of discharge. Inquiries or complaints regarding your medical treatment or violation of your rights may be directed to the Chief Executive Officer or administrative designee of Specialty Hospital. If concerns cannot be resolved through the Specialty Hospital you are encouraged by the Specialty Hospital, without fear of retaliation, to contact the Oklahoma State Department Of Health or The Joint Commission." The admission packet does not explain the grievance process, time frames of investigations, or expectations for a response.

2. On 06/20/2011 , the Patient liaison provided surveyors with an activity log. Multiple unusual patient occurrences were documented in the log. None of the occurrences that required investigation or further follow up were identifed as grievances. Staff A told surveyors Staff C followed up on grievances. In the afternoon of 6/20/2011, Staff C told surveyors follow up documentation was written in the patient charts. Staff C also told surveyors there was no formal report completed by Staff C to present to Quality Committee or Governing Body. Staff C did not know if grievances were reviewed at the administrative level.

3. On 6/20/2011 surveyors reviewed the grievance log. The surveyors asked for all the data and supporting documents concerning Grievances #1, 2, 3, and 4. Data provided did not contain evidence the complaints had been investigated and a written response of the conclusion, with the required information, provided to the complainant. The surveyors asked for any addition information that showed investigation. None was provided.

4. These findings were reviewed with administrative staff on the afternoon of 6/20/2011

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, take action or have a method to identify incidents or patterns to protect patients.

Findings:

1. The hospital's policy titled "risk management-event reporting dated 1/1/2009" stipulates a "1.6.2-quality incident report must be completed for all unusual occurrences". The policy further stipulates "1.6.3 an event that results in an injury or potential injury to a patient requires that a patient's attending physician be immediately notified." The policy also states at 1.6.6 Once completed, the report should go directly to the Department Manager who will forward it to the Quality Management Department within 48 hours.

On the morning of 6/20/11, Staff A told surveyors the facility did not have any incidents other than falls and medication errors.

According to patient #1's medical record, the patient transferred to another room in the facility on 2/4/11. Staff D documented during the transfer the patient complained of burning to the buttocks. Staff D documented observing smoke coming from the oxygen concentrator. Staff B documented turning pt #1, removing the wound vac dressing, and assessing patient #1's skin as "cold, red, hard-skin not open" where the concentrator had been. There was no documentation the physician was notified. On 2/25/11 Staff E the wound management nurse assessed pt #1's skin at the site of the injury and documented "trauma (L) length 3.0cm (W) width 4.0 cm, depth < (less than) 0.1cm." . On 6/20/2011 in the afternoon Staff D told surveyors a incident report had been completed and turned into Staff C.

On the afternoon of 6/20/2011, Staff A told surveyors the facility did not have an incident report for this occurrence. Staff A told surveyors Staff B knew of the incident because of notification through the legal department.

2. The hospital's policy titled "patient family concerns of grievances" provided to surveyors as the grievance policy stipulates "the complaint procedure, included in the admission packet will be explained to the patient and family members during admission by the assigned case manager or social worker. The individual receiving the complaint will initiate the complaint/grievance form and take any steps available to resolve the complaint. After documenting efforts to resolve the complaint, the complaint/grievance form should immediately be given to the appropriate department head. The department head will review the concern and note any additional steps taken to resolve the patient/family's complaint. The completed form should then be submitted to the Quality Management Department within 72 hours. The patient's family will be kept informed of all efforts made to resolve their complaint." The policy further stipulates when the Quality Manager makes the final decision a written response will be provided the complainant. The policy does not define a complaint or a grievance. The policy does not meet the requirements in accordance with CMS guidelines.

On the morning of 6/20/2011, Staff A told surveyors Staff G functioned as the patient liaison. The patient liaison performed patient rounds on all of the patients and kept a log of each interaction. Staff A told surveyors the log was reviewed in a morning leadership meeting. Surveyors reviewed the log from February 2011 through April 2011 and found multiple unusual occurrences on the log. Staff A stated these occurrences were not turned into the Quality Management Department. Staff A stated she was unaware of the information contained in the log.

Occurrence #1 Patient complained electric wheelchair and personal items had been left in the therapy gym. When returned the patient discovered some items missing and was upset. There was no documentation an incident report, complaint or grievance were completed.

Occurrence #2 Patient complained for four consecutive days about dietary supplying milk and juice on the tray. There was no documentation an incident report, complaint, or grievance were completed.

Occurrence #3 Patient complained "its almost impossible to get my call light answered". The log indicates Staff F was told. There was no documentation a incident, complaint or grievance were completed.

Occurrence #4 Patient's family complained they were not informed by the neurologist/cardiologist of what to expect and what was going on with patient. Staff G documented "Staff C plans to go and talk to the family today and or invite them for the Wednesday meeting." There was no documentation a complaint or grievance were completed.

Occurrence #5 Staff G documented "dental hygiene needs attention, pt's mouth was open and had what looked like debris in her mouth. Upon closer inspection it looked like it may have been her mouth deteriorating, it looked black and bloody...I let Staff C know and the pt's nurse." There was no documentation a incident, complaint or grievance was completed.

Occurrence #6 Patient's family complained about multiple issues including call lights not being answered promptly, incorrect diet, did not receive breakfast twice, 45 minute wait for pain meds, and were not instructed on the call light. Staff G documented Staff F is addressing nursing issues. There was no documentation an incident, complaint or grievance was completed.

Occurrence #7 Patient's family complained about room change and the patient being moved to a higher level of care and the family was not notified. Family was also concerned about the patients intake. The day after the complaints were given to the patient liaison, Staff F was notified. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #8 Pt complained equipment was not ready and did not have air mattress even today. The patient also complained about going without food for an extended period of time. Huge confrontation with (name withheld) aide, major issues with (name withheld). The day after the complaints were given to the liaison, the documentation reflects Staff F would be visiting with her today by phone or in person. There was no documentation a incident, complaint or grievance was completed.

Occurrence #9 Pt complained the doctor that visited him was in and out in less than a minute, did not give him any information and was not friendly. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #10 Pt complained the nursing aides were not helping with meals. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #11 Staff G documented calling down to the nurses station as the patient was in excruciating pain. No staff came. Staff H flagged another staff member down to find the patient's nurse. There was no documentation incident, complaint or grievance was completed.

Occurrence #12 Staff G documented "talked with son and told him that I would get with (name withheld) and get the full report from his sister on problems over the weekend so I can make sure it doesn't happen again. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #13 Patient was unhappy with her care. The patient complained of multiple incidents of staff not answering call lights and taking 17 to 30 minutes each time. Staff G documented Staff F was notified about call ight issues. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #14 Patient discussed an incident with Staff G that was of great concern. Patient discussed issues with her assessment. According to the patient, four nurses pulled her dress over her head and when she questioned they said they had to look her over. She asked why the two men had to be present and they told her they all had to be there. This made her uncomfortable. Staff G documented the patient cried during the retelling of the event. The patient also told Staff G a nurse made comments about her weight in the doorway and the patient could hear these statements. A note the following day indicates Staff G notified Staff F. There was no documentation a incident, complaint or grievance was completed.

Occurrence #15 Patient complained about staff being slow at shift change. Patient also complained it took 45 minutes to get a call light answered. There was no documentation a incident, complaint or grievance was completed.

Occurrence #16 patient complained about several "hateful" staff. There was no documentation a incident, complaint or grievance was completed.

Occurrence #17 patient complained the food was dried out and she was not happy with the food. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #18 patient complained about the food. Also the patient stated concerns about agency nurses. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #19 patient complained the call light was not being answered in a timely manner. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #20 patient requested ice at 3pm but did not receive anything until 9pm when the next shift started. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #21 patient's family complained the contract nurses were awful. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #22 patient's family concerned that wound vac had not been put on and the patient has been there two days. Family had not seen doctor yet. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #23 patient reported a big, strong man moved him last week and he thinks he rebroke his ribs w buckle of gait belt during transfer. Staff G documents notified nurse and Dr (name withheld) There was no documentation a incident, complaint, or grievance was completed.

Occurrence #24 patient reported delays in answering the call light. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #25 patient reported incorrect diet. There was no documentation a incident, complaint or grievance was completed.

Occurrence #26 patient reported call light not being answered for 15-20 minutes, at times it is not answered at all, particularly at night. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #27 patient reported call light not being answered promptly. The patient also complained about not getting a wound vac after waiting for two days. There was no documentation a incident, complaint, or grievance was completed.

Occurrence #28 patient's family complained to Staff G "he would rather die than ever be sent here." He said the management is terrible because the patient didn't get wound vac for 2 and a half days after patient arrived. Family also stated the facility was nothing but a glorified rest home and he wanted patient discharged as soon as possible. There was no documentation a incident, complaint or grievance was completed.

Occurrence #29 patient complained about the food quality, temperature, and taste. Staff G documented "horrible". There was no documentation a incident, complaint, or grievance was completed.

Occurrence #30 patient complained about the food quality, temperature, and taste. Staff G documented "food is bad here".

Occurrence #31 patient told Staff G dietary had delivered someonelses tray. The patient told an aide and the aide told the patient to eat it anyway.

3. There was no evidence any of the occurrences were identified as incidents or grievances. The hospital did not follow the incident reporting policy.

4. On the afternoon of 6/20/2011 surveyors reviewed Governing Body meeting minutes for 2011. Incidents reviewed were falls and medication errors. The hospital failed to identify, track, or trend incidents, complaints, or grievances to ensure a safe environment for patients.

Based on the review of abuse and neglect policies and procedures, patient complaints/grievances and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review. The policies concerned emotional/psychological abuse, physical abuse, sexual abuse and neclect concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with hospital Staff on 06/20/11 in the afternoon verified that the hospital does not have a written policy that includes the required elements for effective abuse protection.

3. Hospital staff on 06/20/11, Staff D in the afternoon stated various ways they would handle an allegation of abuse or neglect of a patient or witnessed abuse and neglect. These staff could not identify exactly and verbalize what to do if they witnessed an incident of abuse or neglect of a patient by a staff member.

4. A complaint allegation of possibabuse and neglect verbalized by a patient was discovered during the survey. These complaints ranged from April 2010 through July 2010. There was no evidence that the hospital had taken any action to investigate the allegations.

5. A letter from Staff P alleging abusive treatment by the 3 to 11 staff was discovered in the terminated Nurse Manager's office and there was no evidence that any action had been taken to investigate the allegation.

Based on record review and interviews with hospital staff, the hospital does not ensure that medical errors involving medical equipment and adverse events are investigated and evaluated by clinical staff which include physicians as part of a ongoing Quality Improvement/Performance Improvement program.

Findings:

1. On the morning of 6/20/2011, surveyors requested incident reports for 2011. Staff A told surveyors the facility did not have incidents other than falls and medication errors. Review of the patient liaison log lists multiple unusual occurences ranging from a patient injury, nursing care issues, allegations of abuse, and dietary concerns. There was no evidence these occurrences had been identified as incidents.

2. Review Quality Committee minutes for 2011 did not indicate any incidents had been reviewed other than medication errors and patient falls.

3. Governing Body meeting minutes for the previous twelve months did not have evidence of review of medication errors and adverse events.

4. Staff A told surveyors she was unaware of some of the incidents listed in the patient liaison log.

5. The findings were reviewed with administration in the exit conference. There was no other documentation provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that adverse patient events are investigated and analyzed to assess processes of care and to ensure quality of patient care.

Findings:

1. Patient #1 received burns from equipment used in a procedure.

2. The hospital did not have any evidence that the occurence had been investigated, analyzed and measures taken to prevent a reoccurence.

3. Staff A stated on 06/20/11 in the afternoon that there was no documentation of what the hospital did to investigate the incident. Staff A told surveyors there. There was also no investigation of whether there were other reasons this incident might have occured.

4. The occurance report stated that the radiology department would do a quality assurance ( QA ) investigation of the incident. Review of QA meeting minutes for 2009 which was when the incident occured did not have any evidence of a review of this incident.

Based on review of governing body meeting minutes, performance improvement meeting minutes, medical staff meeting minutes, performance improvement plan 2011, and staff interviews, the hospital 's governing body failed to ensure performance improvement activities were reported, documented, analyzed, implemented, and evaluated.

Findings:

1. The performance improvement (PI) plan 2011 provided to surveyors indicates variance events are defined as non-sentinel events that may have a direct, indirect or potentially adverse effect on the quality fo patient care, any deviation from the most stringent of individual regulatory agencies, state or federal regulations regarding medical records". There was no documentation in the PI plan incidents or grievances would be reviewed, analyzed, trended, and used to improve patient care.

2. Review of Quality Meetings 2011 did not have evidence incidents were reviewed, analyzed, trended and used to improve patient care.

3. The findings were reviewed in the exit conference with administration. No further documentation was provided.