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Based on record review and interview, the hospital failed to ensure the grievance process was implemented as per their policy and procedure as evidenced by failing to identify, investigate, and document patient complaints as a grievance for 5 of 7 patient complaints reviewed from the hospital's complaint log.
Findings:

Review of the hospital policy titled, "Grievance Resolution" (Publication 'RM 30', last reviewed/revised July 2016) provided by S3Quality as current, revealed, in part, "...If the patient care complaint cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, then the complaint is a grievance... If it is necessary to initiate the grievance resolution process, the patient will be provided with a written response... The grievance is resolved when the patient is satisfied wit the actions taken on their behalf, and the hospital has provided the written response...The hospital will maintain documentation of all efforts, and demonstrate compliance."

Review of complaint logs for 2016 and 2017 revealed the following documented complaints:
11/21/16: A complaint made by a patient's granddaughter regarding the patient's missing dentures. Notes included, "Discussed with CEO and corporate risk. Called and left a message for patient's grand daughter but did not receive further communication from her. Under the heading of outcome, documentation noted, "No further contact from family" Further review revealed no documentation of any investigation, interviews, or letter sent to patient or her representative.

11/27/17: A complaint from a patient's daughter documented "missing hearing aid". Notes documented were "investigated, unable to locate, discussed with CEO and corporate risk. Will not replace hearing aid". The complaint was documented as resolved. Further review revealed no documentation of the steps taken to investigate, persons interviewed, details of discussions or advisement from communication with CEO and Corporate Risk Management, or any written correspondence to patient/patient's representative.

12/16/16: A complaint from a patient's daughter documented as. "daughter of patient found item in food. (Daughter) also stated that she had an occasion earlier in the week in regards to water pitcher being left empty all day for the patient. (Patient daughter's name) indicated she had spoken to (named LPN) regarding the matter. Complained that her mother is not being turned every two hours and often the heel boots are not on. Stated she doesn't feel as if the workers are doing their jobs ...wants follow up from Dietary regarding foreign food item and Nursing regarding complaints ...": Further review revealed notes documented as, "Dietary Director investigated ,discussed with staff and contacted patient and daughters. They (were) satisfied with (staff name's) input. (S4RN) nurse manager, spoke with the daughter. She also spoke with the staff to review turning, patient requests, response times, routines for ice water, etc. Daughter satisfied. Encourage to contact us at any time with any concerns. " The outcome was documented as "resolved". Further review revealed no documentation regarding when and by whom the complaint was received, investigative steps taken, by whom, and results. No documentation of any written correspondence to the patient or her representatives.


02/22/17 A complaint entry documented an issue as "feels like we are pushing patient out, case managers not helping, staff rude, would not assist with leaking ostomy". Notes entered regarding the complaint were "CEO, CNO, nurse manager provided support and information to the wife. She is very overwhelmed with husbands illness and personal matters. Lost everything in the flood and is trying to find a place to live and care for husband, currently not able to work due to husband's illness. Reviewed plan of care with the wife, she understood and agreed." The outcome was documented as "resolved." Further review revealed no documentation of any investigative steps to validate the complaints made by the patient's wife. No documentation of when and by whom the complaint was received. Further review revealed no documentation of what, if any, investigative steps were taken and the results of those investigative steps, or of any written correspondence with the patient or his family.


03/05/17: A complaint with no documentation of by whom or when the complaint was received. Notes documented of the complaint were, "To: S1CEO, Cc: S 3 Quality, S4RN (manager), S2CNO;
S1CEO, Mr. (husband of patient) requested to talk to you Monday re: wife R/T staff lack of timeliness to respond to calls for assistance, 1 hours wait for pain meds. Stated he would take her out today if she called him last night. All good last night and today. He did not visit today, so I do not have update from him, but patient states all is ok to charge nurses." Notes documented were, "03/06 spoke with S1CEO,he will contact husband; 03/07 according to S2CNO and S4RN (email)- everything is fine. (Physician) saw them last night and convinced her to stay 1-2 more days. She is very anxious to return home with husband. 03/08 spoke with S4RN and S2CNO apparently pt wanted to leave Monday, issue it to several hours to get ice, did not call a second time. 03/09 husband spoke to S1CEO and S2CNO re CNAs comment to pt regarding bath, pt felt she was spoken to as a child. They wish to be d/c'd today (set for d/c tomorrow anyway). They were happy at d/c, gave nurse (nurse's name) a hug when leaving. This complaint outcome was documented as "resolved" Further review revealed no date, time or by whom this complaint was received. No documentation of investigative steps, such as record review or interviews, into allegations of staff not responding to calls for assistance in a timely manner, the wait for an hour for pain meds, or the alleged lack of dignity with which the patient was spoken to by a CNA.

In an interview 04/05/17 at 2:20 p.m. S3Quality verified the above entries from the complaint log were handled as complaints and were not considered grievances, so no written correspondence had been made to the patients or their representatives. She reported the complaints had not considered to be grievances because they (hospital staff) had been able to talk to the patients or their families and they (patient's and families) seemed to be happy with the situations after talking to them. The hospital's grievance policy and procedure was reviewed with S3Quality and S4RN, after which time, S3Quality confirmed the policy defined a grievance as a written or verbal complaint made to the hospital by a patient or representative related to patient care when not resolved at the time. S3Quality and S4RN both confirmed the policy and procedure listed a complaint resolved at the time of the complaint, by staff present, as a complaint. S3Quality and S4RN confirmed that the reviewed complaints were not resolved, by staff present at the time the complaint was lodged. S3Quality and S4RN agreed the complaints documented for 11/21/16, 11/27/16, 12/16/16, 0-1/04/17, 02/22/17, 03/05/17, and 03/11/17 were not documented as resolved at the time they were reported by staff present, and therefore should have been classified as grievances, and grievance procedures followed. S3Quality verified the information for the reviewed grievances, considered complaints by the hospital, did not have documentation details of investigations into the complaints, findings from those that were "looked into", steps taken to remedy the complaints, or interventions/steps taken to correct deficiencies in policy and procedure or patient care practices, if any.

In an interview 03/05/17 at 2:35 p.m. S1CEO, after a review of the definitions of complaints and grievances in the hospital policy and procedure, and the reviewed complaints, acknowledged that the complaints reviewed from their complaint logs fit the definition of grievances and therefor the grievance process.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure conducted and documented a wound assessment during the initial admit assessment in accordance with hospital policy as evidenced by failure to have documented evidence of a wound assessment by the admitting RN for 2 (#1, #2) of (#1, #2,#4) patient records reviewed for wound assessments from a total sample of 5 patients.
2) Failing to ensure the RN implemented physician orders for blood administration (#2) and lab work (#2) for 1 (#2) of 5 (#1-5) patient records reviewed for implementation of physician orders from a total of 5 patient records.
3) Failing to document patients were turned or repositioned every 2 hours, when the patient was unable to do so independently for 1(#4) of 2 (#4, #5) patients reviewed requiring assistance with repositioning from a total sample of 5.
Findings:

1) Failing to ensure conducted and documented a wound assessment during the initial admit assessment in accordance with hospital policy:
Review of the hospital policy titled "Assessment/Reassessment Nursing", presented as a current policy by S3Quality, revealed that a nursing assessment is completed on all patients admitted to the hospital. The admission process must be supervised by a RN who will identify patient care needs and initiate the plan of care. All other data elements will be completed by the RN or LPN within their scope of practice within 24 hours of admission. Further review review revealed "The Lippincott Manual of Nursing Practice" serves as the assessment guidelines for assessment and reassessment. The physical and psychological assessment includes a body system examination and wound/risk assessment.

Review of the hospital policy titled "Wound Care Management", presented as a current policy by S3Quality, revealed that patients are consulted upon admission or who develop wound(s) will receive appropriate wound care management by an interdisciplinary team based on physician orders. Each wound is photographed by the Wound care team on initial assessment which is defined as 72 hours or next business day of admit date, weekly, and as needed for major changes in the wound. Further review revealed an initial wound assessment is completed by the RN on the Initial Nursing Assessment. The RN will perform a head to toe skin assessment and obtain an order for appropriate dressings as outlined in the Initial Wound Assessment/Treatment Policy.

Review of the hospital policy titled "Wound Assessment Treatment Initial", presented as a current policy by S3Quality, revealed that the staff nurse is to initiate wound care on newly admitted patients and those developing new wounds if the Wound Care Nurse is unavailable for immediate assessment of the patient's wounds. The nurse is to remove all dressing from wound(s), cleanse with normal saline, and measure per guidelines, and document in the medical record.

Patient #1
Review of Patient 31's medical record revealed he was admitted on 03/30/17 with a diagnosis of right medial thigh wound and a history of Hypertension, Pulmonary Artery Disease, and Coronary Artery Disease.

Review of Patient #1's "Initial Nursing Assessment", conducted on 03/30/17 at 3:45 p.m. by S10RN revealed documentation of a pressure wound to the right leg. There was no documented evidence of the color of the skin, the presence or absence of odor, the presence or absence of drainage, and a description of the dressing and surrounding tissue, as evidenced by columns on the "Wound Description" being blank of documentation.

Review of Patient #1's "Wound Assessment", documented by S5RN on 03/31/17 at 6:30 p.m. (26 hours 45 minutes after admission) revealed the following wounds were present: right inner thigh proximal; right inner thigh surgical distal; right medial lower leg; right lateral thigh inferior; right groin; right anterior thigh; right lateral thigh superior.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 03/08/17 with a diagnosis of Stage 3 pressure injury left hip and Stage 4 pressure injury sacrum.

Review of Patient #2's "Initial Nursing Assessment", conducted by S12RN on 03/09/17 at 5:00 a.m., revealed the "Wound Description" included pressure wounds to the sacral, right ischial, left lower leg, and right lower limb. Further review revealed the description of the dressing and surrounding tissue for the sacral and right ischial was documented as "irregular", and the description for the left lower leg and right lower limb was documented as "pink." There was no documented evidence of the description of the dressing for all wounds and the surrounding tissue for the sacral and right ischial wounds.

Review of the nurse practitioner's wound care orders documented on 03/10/17 at 12:35 p.m. revealed the following wounds: sacrum; right ischium; posterior proximal thigh linear wounds; left ischial; bilateral lower leg wounds.

In an interview on 04/04/17 at 1:52 p.m., S5RN indicated the admit RN nurse is supposed to document a wound assessment unless the sending facility says the patient has had wound care that day. In that case, the RN admit nurse is supposed to let the physician know and document approval for deferral of the assessment. Regarding Patient #1, S5RN indicated when she saw the patient on 03/31/17, the dressing on his legs were dated 03/29/17. She further indicated she saw the sending facility had been doing Hydrocolloid every 4 days, and that may be why the admit nurse didn't look at the wounds. S5RN indicated there should be a physician's order if the wound assessment is to be deferred. After review of Patient #1's medical record, she confirmed she saw no order to hold wound assessment; and she saw no documentation of a wound assessment by the admit nurse. Regarding 26 hours 45 minute delay in her wound assessment, S5RN indicated she had to wait for the patient to be medicated prior to doing her assessment. After reviewing Patient #2's admit assessment, S5RN confirmed there was no documented evidence of a wound assessment as stated above.

2) Failing to ensure the RN implemented physician orders for blood administration and lab work:
Blood Administration:
Review of Patient #2's physician orders revealed an order on 03/31/17 at 5:00 p.m. to administer 2 units of blood, each to run over 4 hours, and to administer Lasix 20 mg IV after each unit of blood.

Review of Patient #2's medical record (medication administration records, nursing flowsheets) revealed no documented evidence that Lasix 20 mg IV was administered after the second unit of blood.

In an interview on 04/04/17 at 4:15 p.m., S3Quality confirmed there was no documented evidence in Patient #2's medical record that she was given the Lasix 20 mg IV after the second unit of blood was administered.

Lab Work:
Review of Patient #2's physician orders revealed an order on 03/23/17 at 4:30 p.m. to test stools for C-Diff.

Review of Patient #2's lab results revealed no documented evidence of a C-Diff stool result.

In an interview on 04/04/17 at 3:27 p.m., S3Quality confirmed the order reads C-Diff, and the lab results have no evidence of C-Diff results. She indicated when she contacted the lab, she was told the lab canceled the C-Diff test, because a formed stool was sent. She further indicated it's an automatic cancellation by the lab when a formed stool is sent.

In an interview on 04/04/17 at 4:15 p.m., S3Quality confirmed she saw no documentation in Patient #2's medical record that the physician was notified of the C-Diff lab test being canceled by the lab.

3) Failing to document patients were turned or repositioned every 2 hours, when the patient was unable to do so independently.

Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital for wound care and antibiotics related to a group B Strep bacteremia from osteomyelitis of the right foot along with mitral valve endocarditis and septic emboli to the brain. Further review revealed other medical problems included Chronic ESRD, DM, Gastroparesis, GERD, Anxiety, HTN, and Anemia secondary to CKD. She was assessed on admission to need total assistance for bed mobility, ADLs, and hygiene. She was documented as incontinent of bowel and bladder.
Review of nursing flowsheets revealed no documentation for position change 03/04/17 from 7:00 a.m. to 7:00 p.m. with the exception a narrative note at 9:00 a.m. stating the patient was up in a wheelchair for therapy. Review of a Nursing Daily Flowsheet dated 03/0717 under Activity revealed "self" written across the line for position change from 7:00 p.m. through 6:00 a.m. (night shift). No documentation was noted on the line from 7:00 a.m. through 6:00 p.m. (day shift). Further review revealed narrative nurses notes for 03/07/17 to include the following: 8:00 a.m. "Patient currently out of room for procedure at (acute care hospital) per Dr.", and 12:30 p.m., "Patient returned from procedure in stable condition.. Neuro check (of right arm after thrombectomy of her dialysis graft), and at 2:00 a.m. a nursing note documented the patient had a loose stool. Review of the Nursing Daily Flowsheet and Nursing narrative notes for 03/08/17 revealed the documentation line on the daily flowsheet, under Activity: Position Changed had no documentation from the 7:00 a.m. space through the 6:00 p.m. spaces, and "self" written with a line drawn across from 7:00 p.m. through 6:00 a.m. Further review of the narrative notes for 03/08/17 revealed, in part the following hand written notes: 7:30 a.m. "...patient sleepy, arousable with moderate stimulation...R arm has no movement patient being brought to dialysis at present...", and 11:30 a.m., "patient back from dialysis...", 1:00 p.m. "Pt OOF (off of floor) ...for CT of head without contrast", and 3:00 p.m., "Pt returned from CT, awake, alert, verbal...husband at bedside."


In an interview 04/04/17 at 2:20 p.m. S4RN, Nursing Manager , after a review of the medical record for Patient #4, verified there were blanks in the spaces for documentation of turning/repositioning the patient on the Nursing Daily Flowsheet. S4RN verified that the documentation in the medical record did not reflect that Patient #4 was turned every 2 hours while in bed. She pointed out some narrative notes as to when the patient left the floor or the hospital, but agreed not all times when the patient was out of bed were included and it was not possible to tell if the patient had been repositioned every two hours while she was in bed without the documented evidence.



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Based on record reviews and interview, the hospital failed to ensure each patient had a current nursing care plan developed and implemented that included identified problems, interventions, measurable goals, target dates for completion, the person responsible to implement the interventions, and a plan for all medical problems for which the patient is being treated as evidenced by failure to have these components addressed in the nursing care plan for 3 (#1, #2, #4) of 3 (#1, #2, #3)) patient records reviewed for care plans from a total of 5 sampled patients.
Findings:

Review of the policy titled "Nursing Documentation", presented by S3Quality when a request was made for the hospital's nursing care plan policy, revealed that the care plan is to list the functional patient problems requiring intervention by the nursing staff. Educational goals were to include identified educational needs the patient may have. There was no documented evidence that the policy included the components of the care plan, such as interventions, measurable goals, target dates for completion, the person responsible to implement the interventions, and a plan for all medical problems for which the patient is being treated.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 03/30/17 with a diagnosis of right medial thigh wound and a history of Hypertension, Pulmonary Artery Disease, and Coronary Artery Disease. Further review revealed he was admitted with a diagnosis of status Gastrointestinal Bleed and had received transfusions at the acute care hospital.

Review of Patient #1's "Interdisciplinary Plan Of Care" revealed the identified problems included impaired gas exchange, altered comfort/pain,infection, and impaired skin integrity. Further review revealed no documented evidence that all problems included interventions to be implemented, goals that were stated in measurable terms, target dates for completion of each goal, and the person responsible for the intervention. Further review revealed no documented evidence that a care plan had been developed for fluid/volume deficit (status post gastrointestinal bleed) and Hypertension, for which he was being treated.

Patient #2
Review of Patient #2's medical record revealed she was admitted with diagnoses of Stage 3 pressure injury to the left hip and Stage 4 pressure injury to the sacrum. Further review revealed a history of chronic paraplegia; acute renal failure secondary to intravascular volume depletion; catheter-related bacteuria; Macrocytic anemia; and electrolyte disturbances.

Review of Patient #2's "Interdisciplinary Plan Of Care" revealed the identified problems included impaired mobility, decline in activities of daily living, impaired gas exchange,altered comfort/pain, fluid volume excess, altered nutrition, altered urine elimination, actual infection, impaired skin integrity, high risk for impaired skin, risk for spread of infection, and risk for decreased cardiac output. Further review revealed no documented evidence that all problems included interventions to be implemented, goals that were stated in measurable terms, target dates for completion of each goal, and the person responsible for the intervention.

Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital for wound care and antibiotics related to a group B Strep bacteremia from osteomyelitis of the right foot along with mitral valve endocarditis and septic emboli to the brain. Further review revealed other medical problems included Chronic ESRD, DM, Gastroparesis, GERD, Anxiety, HTN, and Anemia secondary to CKD. Review of the History and Physical on the patient was noted to have problems with nausea. Review of Patient #4's MAR revealed she received Lorazepam, for anxiety on 03/04/17 at 1:00 a.m. and at 9:15 a.m., 03/05/17 at 10:00 p.m., and again 03/06/17 at 9:30 p.m. for anxiety. Further review of the medical record revealed the patient received dialysis three times a week, and had a diabetic, renal diet ordered.

Review of Patient #4's "Interdisciplinary Plan Of Care" revealed the identified problems documented for Patient #4 did not included altered nutrition related to her Diabetes, Chronic Kidney Disease (requiring dialysis), or her nausea and vomiting, Fluid volume excess (related to her dialysis), Ineffective Coping (related to diagnosis of Anxiety), or any Knowledge Deficit. Further review revealed no documented evidence that all problems included interventions to be implemented, goals that were stated in measurable terms, target dates for completion of each goal, and the person responsible for the intervention.


In an interview on 04/04/17 at 2:13 p.m., S4RN confirmed Patient #1's goals for impaired gas exchange and altered comfort/pain are incomplete. She indicated a patient who had a gastrointestinal bleed should have a plan for fluid volume deficit. She confirmed the wound goals are broad and not measurable, and the other medical diagnoses should have been care planned. S4RN confirmed there was no documented evidence of target dates and the person responsible for interventions in Patient #1's and Patient #2's care plan. She further indicated they have been working with corporate to address the care plan to add target dates, but she doesn't have any documentation to reflect the discussion.

In a interview 04/04/17 at 2:20 p.m. S4RN confirmed Patient #4's care plans did not address her altered nutritional needs , potential or actual fluid volume excess related to her dialysis, Anxiety, or knowledge deficit. She indicated these problems should have been care planned for Patient #4.





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