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Based on record review and interview, the facility failed to specify timeframes for review of grievances and the provision of a response in its policies.

Findings include:

On 3/25/20 in the afternoon, the facility's Grievance process was reviewed. The Quality Assurance Director Intern provided the Grievance/Complaint Process policy (dated 3/2006) and the Patient Right For Complaints policy (revised 2/01/15). The policies lacked documented evidence the facility specified a timeframe for review of grievances.

Once informed of the above, the Quality Assurance Director Intern provided a document entitled Complaint Response Guidelines for use in the quality department. Directives included in the document were not included in the facility's aforementioned policies.

Based on record review and interview, the facility failed identify and inform grievants of processes and steps taken to investigate grievances, the results of the grievance process and the date of completion.

Findings include:

On 3/25/20 in the afternoon, random grievance letters were reviewed. One letter dated 10/09/19 and another dated 10/25/19 to grievants showed the response letters were identical, except for one sentence describing the particular concern. Both letters lacked documented evidence of the steps taken to investigate the grievances.

On 3/25/20 in the afternoon, the Quality Assurance Director Intern acknowledged the letters lacked clarity regarding the steps taken to investigate the grievances.

Based on record review, interview and policy review, the facility failed to ensure patients with soft wrist restraints applied were monitored every 2 hours for 2 of 6 patients with restraints (Patient #6 and #7).

Findings include:

Patient #6

On 2/20/20, Patient #6 was admitted with sepsis, flu and pneumonia.

On 3/15/20 at 6:31 AM, a physician ordered restraint checks every 2 hours.

The restraint administration history showed a nurse documented a completed restraint check at 5:52 PM on 3/15/20. The next completed restraint check was documented at 8:42 AM on 3/16/20. The corresponding nursing assessments showed a nurse documented the patient was in restraints.

On 3/25/20 at 2:30 PM, the Director of Nursing acknowledged the restraints were documented as applied, but the monitoring assessments were not completed every 2 hours.

Procedure 1E(1) of the Restraints policy (section R revised 11/01/2014) revealed the use of restraints would be frequently evaluated (at a minimum of every two (2) hours).

Patient #7

On 1/30/20, Patient #7 was admitted with septicemia, acute respiratory failure with hypoxia and pneumonitis.

On 3/08/20 at 7:25 AM, a physician ordered restraint checks every 2 hours.

The restraint administration history showed a nurse documented a completed restraint check at 1:04 AM on 3/09/20. The next completed restraint check was documented at 8:40 AM on 3/09/20. The corresponding nursing assessments showed a nurse documented the patient was in restraints.

On 3/09/20 at 7:20 AM, a physician ordered restraint checks every 2 hours.

The restraint administration history showed a nurse documented a completed restraint check at 6:46 PM on 3/09/20. The next completed restraint check was documented at 8:39 AM on 3/10/20. The corresponding nursing assessments showed a nurse documented the patient was in restraints.

On 3/25/20 at 2:30 PM, the Director of Nursing acknowledged the restraints were documented as applied, but the monitoring assessments were not completed every 2 hours.

Procedure 1E(1) of the Restraints policy (section R revised 11/01/2014) revealed the use of restraints would be frequently evaluated (at a minimum of every two (2) hours).

Based on record review, interview and policy review, the facility failed to ensure nursing assessments/reassessments were completed for 3 of 10 patients (Patient #1, #2 and #3).

Findings include:

Patient #1

1. On 3/13/20, Patient #1 was admitted with acute respiratory failure with hypoxia.

On 3/14/20 at 4:33 PM, Norco was ordered every 6 hours as needed as per a Nurse Practitioner.

On 3/14/20 at 4:46 PM, a Registered Nurse documented administering the Norco in a progress note.

The medical record lacked documented evidence any nurse re-evaluated the patient's pain afterward for the effectiveness of the Norco.

On 3/25/20 at 11:05 AM, the Registered Nurse in question acknowledged administering Norco on the afternoon of 3/14/20, but did not recall if there was a pain reassessment.

The medical record lacked documented evidence of a pain reassessment.

On 3/25/20 at 3:35 PM, the Director of Nursing acknowledged the effectiveness of administering pain medication should be assessed some time after administering the medication.

Procedure #4D of the Pain Management policy (section P-2 revised 11/01/2014) revealed to evaluate pain relief after medication administration within 30 minutes to 1 hour.

2. The medical record documented a nurse last assessed Patient #1's pain at 7:48 PM on 3/20/20, and a nurse did not assess Patient #1's pain again until 7:22 PM on 3/21/20.

On 3/25/20 at 10:15 AM, the assigned Registered Nurse acknowledged failing to document a nursing assessment and pain assessment during the day shift on 3/21/20.

Procedure #1 of the Pain Management policy (section P-2 revised 11/01/2014) revealed upon admission and every shift, the assigned nurse would determine the presence of pain. Procedure #2 revealed patients would be reassessed for pain every 12 hours, after the administration of pain medication, or more frequently, as their condition warranted.




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Patient #2

Patient #2 was admitted on 3/16/20, with diagnoses including hemiplegia, arthritis and aphasia.

There was no initial nursing admission assessment completed for the patient.

On 3/24/20 in the afternoon, the Director of Medical Records confirmed there was no electronic or hard copy Nursing Admission History assessment form completed for the patient.

On 3/24/20 in the afternoon, the Chief Clinical Officer and the Director of Nursing (DON) confirmed the patient's initial admission nursing assessment should have been completed within 8 hours of the patient's admission and Patient #2's was not completed.

The facility's policy dated 11/1/2014 and titled Admission, Assessment and Reassessment Policy indicated the admission assessment was to be completed within 8 hours of the arrival to the unit.

Patient #3

Patient #3 was admitted on 9/26/19, with diagnoses including epilepsy, tracheostomy, gastric ulcer and rheumatic disorder.

The shift reassessment form consisted of areas in which the nurse had to reassess their patient during their shift. The assessment areas included:

-Cardiac
-Pulmonary
-Psychological
-Intravenous access
-Pain
-Gastrointestinal
-Genitourinary
-Safety

There were no shift reassessments for Patient #2 on the following days:

-Day shift on 3/17/20
-Day shift on 3/23/20

On 3/25/20 in the afternoon, the DON indicated a patient shift reassessment was completed for every shift by the nursing staff and there were two shifts a day. The DON confirmed there were no shift reassessments completed for Patient #2 on the day shift on 3/17/20 and 3/23/20.

Complaint #NV00060557

Based on interview, record review and document review, the facility failed to create an initial care plan for 1 of 5 sampled patients.

Findings include:

Patient #2

Patient #2 was admitted on 3/16/20, with diagnoses including hemiplegia, arthritis and aphasia.

The patient had no completed care plans and two incomplete care plans which were potential for injury and the other was for alteration in skin integrity.

The alteration in skin integrity care plan had no time frames for achievement, interventions, discipline specific services and frequency.

The second care plan only listed the problem which was potential for injury and the patient diagnosis. There was no other documentation on the care plan such as interventions, goals, time frames and resolution.

On 3/24/20 in the afternoon, the Director of Medical Records and the Director of Infection Control confirmed there were no completed care plans for the patient.

On 3/25/20 in the afternoon, the Chief Clinical Officer and the Director of Nursing confirmed there were no care plans completed for the patient.

The facility policy dated 11/1/2014 and titled Care Plan Process, indicated an initial care plan consisted of a date, problem, goals (measurable and realistic), time frames, interventions (discipline specific and frequency), resolution and discharge options.
The policy indicated an initial care plan should be completed within 24 hours based on the physician orders and the initial nursing admission assessment. The interdisciplinary team should create a the care plans within 7 days after admission.

Based on record review and interview, the facility failed to document an order for a pain consult and failed to
conduct a follow-up pain reassessment after administering pain medication, and the provider who conducted the pain consult denied ordering pain medication despite signing the order.

Findings include:

Patient #1

On 3/13/20, Patient #1 was admitted with acute respiratory failure with hypoxia.

On 3/14/20 at 4:33 PM, Norco was ordered every 6 hours as needed as per a Nurse Practitioner.

On 3/14/20 at 4:34 PM, Tylenol was ordered every 6 hours as needed.

On 3/24/20 at 2:00 PM, the Pharmacist provided a document showing, on 3/14/20 at 4:37 PM, a Registered Nurse withdrew Norco from the facility's main automatic drug dispenser according to the Pharmacist.

On 3/14/20 at 4:46 PM, a progress note showed a Registered Nurse administered Norco to the patient.

The medical record lacked documented evidence any nurse reassessed the patient for pain relief afterward. The same Registered Nurse documented a progress note administering routine medication after 6:00 PM, but the nurse failed to mention pain reassessment.

On 3/25/20 at 1:00 PM, the Nurse Practitioner acknowledged receipt of a request for a pain consult at 4:03 PM on 3/14/20, but the Nurse Practitioner denied ordering pain medication.

Patient #1's medical record lacked documented evidence of an order for a pain consult.

On 3/17/20, the Nurse Practitioner documented a pain consult, showing the patient's case was reviewed with the current pain control regimen. The parameters for pain medication were discussed with a nurse. The Nurse Practitioner signed the order for Norco (from 3/14/20) during the same visit the pain consult was conducted.

On 3/24/20 at 3:15 PM, the Nurse Practitioner was unable to recall the Norco order, despite signing the order.

On 3/25/20 at 11:05 AM, the Registered Nurse in question acknowledged administering Norco on the afternoon of 3/14/20, but did not recall if there was a pain reassessment.

The medical record lacked documented evidence of a pain reassessment.

On 3/25/20 at 3:35 PM, the Director of Nursing acknowledged consults should have documented orders to carry them out, and the effectiveness of administering pain medication should be assessed some time after administering the medication.

Procedure #4D of the Pain Management policy (section P-2 revised 11/01/2014) revealed to evaluate pain relief after medication administration within 30 minutes to 1 hour.



Complaint #NV00060557