HospitalInspections.org

Based on observation, record review and staff interview, it was determined the hospital failed to ensure patients and/or their representatives were aware of the right to a written response when a grievance was reported to the facility. Findings:

A hospital policy, titled Patient Complaints and Grievances, documented, "... the [grievance] committee shall provide a written response to the grievance within 10 working days. If the grievance will not be resolved or the investigation not completed within 10 working days, the hospital will inform the patient or the patient's representative that the hospital is still working to resolve the grievance and the hospital will follow up with a written response with a stated amount of time..."

On 06/11/12, the CEO was asked to provide written information regarding patient rights regarding complaints and grievances given to patients and/or their representatives upon admission to the hospital.

A packet of information, titled Hospital Admission Documents, included notice of patient rights and the complaint/grievance process.

The information did not include notice the hospital would provide a written response to a grievance.

Patient Rights notices posted by the public elevator to the Solara Hospital did not include information about rights regarding complaints or grievances.

Patient Rights notices posted near the employee time clock did not include information the hospital would provide a written response to a grievance.

The CEO and the DON were asked if patients and/or their representatives were notified of the right to a written response when a grievance was voiced.

They stated they were not notified.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Three (#4,5,6) of three grievances ( #'s 4, 5,6) grievances/ complaints reviewed met the definition of a grievance but did not have all required documentation or elements.

Findings:
1. Grievances #5, (which required investigation and follow up) did not have evidence of a letter being sent to the complainant.

2. Grievance #4 . The complainant made multiple complaints which required investigation on multiple days. The initial complaint was addressed with a letter. None of the other complaints (which required investigation) were addressed through the grievance process. .

3. Grievance #6 The complainant received a letter. The letter did not address all of the complaints. There was no information to the complainant as to steps taken on behalf of the patient.

4. On 6/11/2012 the above information was shared with administration. There was no further documentation.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. ensure basic nursing care, regular skin assessment and skin care/treatment was provided to prevent the development of wounds;

b. ensure proper identification and assessment of wounds present upon admission;

c. obtain a physician's order and ensure there was a clinical rationale for the use of a Foley catheter; and

d. failed to follow physician's orders related to mobility/physical therapy for three (#1, 2, 3) of four sampled patients.

Findings:

A hospital policy, titled Patient Assessment and Reassessment, documented, "... Assessment includes the conducting of appropriate observation and/or examination procedures and the recording, reporting and evaluation of such data as is necessary for the identification and establishment for each patient's 'working' diagnosis, patient problems or care needs...

All patients are seen within 24 hours of the initial request for consult. Departments which normally operate within the Monday-Friday work schedule will see patients within one working day after the initial request for consult is made...

The admitting nurse is responsible for initiating referrals to ancillary disciplines...

Each patient is reassessed at regularly specified times... to determine the patient's response to treatment, when a significant change occurs in the patient's condition... The assessments are documented on the patient care record... it will be the responsibility of the Charge RN or his/her designee to perform an assessment and chart any change and action taken...

Nursing Care:... The RN is responsible and accountable for prescribing, delegating, and coordinating all nursing care...

The medical record should contain at least the following evidence that the nursing process is used in documenting patient care:

~ the initial assessment and evaluation performed by an RN and/or other qualified nursing members... and all reassessments required by the patient's condition and/or policies and procedures...

~ the nursing care provided to the patient...

~ the effectiveness/outcomes of nursing interventions..."

A hospital policy, titled Skin Integrity Check, documented, "... Skin Integrity checks will be completed each shift... and PRN to ensure skin/wound problems are assessed and treated in a timely manner...

Skin integrity checks are to be completed by a CNA (certified nursing assistant), PCT (patient care technician), PCA (patient care assistant) no less than every shift and PRN...

CNA/PCT/PCA to perform full body skin integrity checks during patient bath... during toileting, cleaning and changing of patient and patient gowns, linens..."

A hospital policy, titled Pressure Ulcer Prevention, documented, "... Observe skin daily... incontinence checks every two hours... cleanse with PH balanced no-rinse cleanser or soap and water... moisturize skin... no diapers while in bed... assess for scheduled toileting...

Pressure Reduction: Change position in bed or chair at least every two hours... maintain head of bed less than 30 degrees... Utilize pressure reduction mattress or overlay... Do not position on pressure affected areas...

Mobility/Exercise: Assess for mobility/positioning... Participation in exercise program... assess for ambulation and/or active/passive ROM [range of motion]..."

1. Patient #1 was admitted to the hospital from an emergency room with diagnoses which included COPD and acute respiratory failure.

An admission nursing assessment documented the patient had no wounds upon admission, but was at risk for skin breakdown. The patient was assessed to be continent of bowel and bladder.

On 03/01/12, physician's admission orders documented the patient was to be evaluated and treated by physical therapy.

On 03/02/12, nurse's notes documented a Foley catheter was inserted. The notes documented the patient complained her abdomen felt full and that she was tired of using the bedpan.

There was no documentation of a physician's order for the insertion of a Foley catheter.

On 03/03/12, the physician ordered the patient to be out of bed daily with assistance and to use the bedside commode if possible.

On 03/06/12, the patient was assessed to be at high risk for skin breakdown.

On 03/09/12, the physician re-ordered physical therapy to evaluate and treat. (There was no documentation that indicated the patient was evaluated and treated by physical therapy as ordered on 03/01/12.)

Braden Scale skin assessments completed by the nursing staff on 03/13/12 and 03/20/12 documented the patient was at high risk for skin breakdown.

On 03/14/12, the physical therapy department performed an evaluation for treatment. This was 14 days after the original order and five days after the repeat order.

Daily skin assessments through 03/20/12 documented the patient had no wounds.

On 03/21/12, a left buttock wound was documented on a daily body diagram. There was no documentation of wound assessment and no documentation of interventions provided by the nursing staff to care for the wound.

On 03/22/12, the physician ordered Xenaderm ointment to the peri-sacral area twice a day and as needed.

On this date, nursing staff documented a left buttock wound on the daily body diagram and described it as "... blisters popped..."

On 03/23/12, nurse's notes documented, "... Pt has partial thickness... ulcer to [bilateral] buttocks. Wound bed pink, [no] drainage. Xenaderm applied..."

On 03/26/12, nurse's notes documented the patient was incontinent of stool twice while in bed. There was documentation the nursing staff provided incontinent care.

There was no documentation of skin assessment or wound assessment. There was no documentation of wound treatment.

On 03/27/12, nurse's notes documented the patient was incontinent of stool while in bed. The patient was placed on the bedside commode. There was no documentation of skin/wound assessment or of wound treatment at the time of incontinent care.

A physician's order, dated 03/27/12, documented, "... Start bladder training now and [discontinue] Foley by AM on 03/28/12..."

This was the first physician's order related to the Foley catheter. No order had ever been obtained to insert the catheter.

On 03/28/12, the buttocks wound treatment orders were changed and documented, "... cleanse with normal saline, pat dry, apply medicine and cover with softer, tape [with] mediocre tape daily and [as needed]..."

On 03/28/12, nurse's notes documented, "... diaper saturated with urine. Will use bedpan..." There was no documentation of skin and wound assessment. The wound dressing was described as "clean, dry and intact."

On 03/30/12, nurse's notes documented the wound dressing was saturated with urine. There was no documentation of the wound or if the dressing was changed.

There were no wound assessments documented for 03/31/12, 04/01/12 or 04/02/12.

The patient was discharged on 04/02/12 with orders to continue wound care and to continue physical therapy.

Daily wound care and "as needed" wound care was not documented by the nursing staff in the clinical record during the entire course of the hospitalization.

The clinical record had no documentation of nursing assistance with personal hygiene to include bathing, oral care, peri care or back care on 15 out of 33 days.

Partial hygiene care (oral care or peri care only) was documented on four days.

There was no documentation of basic nursing care to prevent or help treat wounds such as:

assisting the patient to change positions frequently while in bed,

assisting the patient to sit in a chair daily as ordered by the physician,

regular, timely assistance with transferring to the bedside commode to prevent incontinence; and

the use of pressure relieving devices for the bed and the chair.

2. Patient #2 was admitted to the hospital with diagnoses which included MRSA sepsis, stage IV ischeal decubitus and paraplegia.

Physician admission orders, dated 03/22/12, documented wound care orders and physical therapy to evaluate and treat.

The clinical record documented the physical therapy evaluation was done on 03/27/12.

There was no documentation of daily wound assessments or daily/as needed wound care provided by the nursing staff.

The only wound care documentation was of the wound physician's debridement procedures.

During the patient's hospitalization, personal hygiene (to include bathing, oral care, back care and pericare) was not documented on 22 of 33 days.

There was no documentation of additional wound treatment measures such as frequent repositioning and pressure relieving devices.

3. Patient #3 was admitted to the wound management service with infected wounds on bilateral feet per history and physical. The patient had a history of diabetes requiring insulin, drug use and obesity.

Documentation on the initial nursing assessment did not include skin assessments.

The initial wound care nursing assessment on 5/10/2012 documented left foot ulcers with pictures. There was no documentation of the right toe ulcer that was present on admission.

On 5/14/2012 the wound care nurse documented the right great toe wound. There was no documentation of assessment or treatment of this wound after this date.

Multiple days of the patient's stay had no documentation of hygiene (bath, oral care, pericare).

On 5/10/2012 the physician wrote orders for physical therapy to evaluate and treat. There was no physical therapy evaluation documented.

On 5/19/2012 physical therapy was ordered daily three to five times a week. There was no documentation the patient received physical therapy.

There was no nutritional screen or assessment provided for the patient throughout the stay.

On 06/11/12, the DON was informed of the findings and he examined the medical records. No comment was made.