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Based on record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 3 (#1, #20, #21) of 3 patients reviewed for complaints/grievances from a total patient sample of 30.

Findings:

Review of the hospital's policy titled, "Patient-Family Grievances", A.1.02 revealed in part:
Definitions: Patient/Family Complaint is defined as a patient/family member/representative's expression of displeasure or dissatisfaction with service received. A resolution is achieved at the time of the complaint, by staff present or who can quickly be at the patient's location to resolve the complaint.
Patient/Family Grievance is defined as something that affords just cause for complaint or protest; and/or an issue unresolved following normal complaint procedure that cannot be resolved promptly by staff present It can be submitted in written or oral form by patient and/or family member or representative, regarding patient care, abuse or neglect, or issues related to the hospital's compliance with CMS requirements.
A.Complaints: 4. If patient, family member and/or family representative is still unsatisfied or if the verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is considered a grievance.

Patient #1
Review of a complaint/grievance report dated 07/19/2019 at 9:30 p.m. revealed Patient #1's spouse had complained about the previous night shift staff being rough when it came to turning his wife and he indicated her skin tore easily. He also indicated nursing staff failed to communicate why his wife was there and what therapy she would need during her stay.

Further review revealed S1CCO had investigated Patient #1's spouse's complaint and had identified it was a CNA who could not answer his questions and who had been rough when turning his wife. Additional review revealed the staff was educated as to their role in caring for patients and need to introduce themselves. The documentation indicated this was classified as a complaint, not a grievance, and no letter had been sent to the complainant.

Patient #20
Review of a complaint/grievance report dated 04/14/2019 at 08:39 a.m. revealed Patient #20 had indicated her sciatic pain had increased and she had called for assistance to be repositioned. After ½ hour passed with no response, she called for the nurse to get a pain medication for relief. She reported it took another ½ hour before someone arrived. She also reported she had heard the CNA speaking about her in a negative way and it had upset her greatly.

Further review of the report revealed the Administrative staff on call had spoken with the patient and assured her the night shift would be counseled, the CNA would be spoken to regarding the issue, and S1CCO would be informed of her complaint. The Administrative staff on call had also informed the patient that actions would be taken to remediate the situation and prevent further incidents from occurring.

Additional review revealed S1CCO had documented review of the patient's medication administration record for pain medication administration times, had reviewed the times the medications had been pulled from the Omnicell medication dispensing unit, had interviewed staff and had identified nursing staff had failed to notify the patient's physician that the pain relief from the patient's ordered medication was not lasting until the next dose could be given. S1CCO's documentation indicated staff had been educated as a result of the investigation. S1CCO's documentation also indicated this was classified as a complaint, not a grievance, and no letter had been sent to the complainant.

Patient #21
Review of a complaint/grievance report dated 05/02/2019 at 9:30 p.m. revealed Patient #21 was reportedly found, by her caregiver, with the Foley catheter bag hanging on the bedrail, soaked in urine from chest to knees with puddling of urine between her legs. The caregiver also reported the patient had a bowel movement that had not been cleaned and she smelled very strongly of urine. The caregiver had reported she thought the catheter had leaked on the floor.

Further review of the incident report documentation revealed S3RN, Patient #21's primary nurse, had discussed the complaint with the sitter. Staff apologized for the incident and assured sitter frequent rounds would continue and the complaint would be written up and reported.

Additional review revealed S1CCO had been notified of the complaint by the charge nurse the next morning. S1CCO documented she had apologized to the family and assured the family involved staff would be educated. She indicated the family had requested concerns should be discussed with them and not the sitter in the future. S1CCO documented she had spoken with the staff involved and they had been educated regarding failure to follow established procedures. S1CCO's documentation also indicated this was classified as a complaint, not a grievance, and no letter had been sent to the complainant.

In an interview on 02/05/2020 at 07:50 a.m. with S1CCO, she confirmed she had not classified the above referenced reported issues involving Patient #1, Patient #20, and Patient #21 as grievances. She indicated she had felt the issues had been resolved and had considered them complaints and not grievances. S1CCO confirmed letters had not been sent to the complainants.

Based on record review and interview, the hospital failed to ensure any incidents of abuse or neglect were reported as required by applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by failure of the hospital to recognize a patient caregiver's complaint as an allegation of neglect of care and failing to report the incident within 24 hours to Louisiana Department of Health- Health Standards Section for 1 (#21) of 3 (#1, #20, #21) sampled patients' complaints reviewed.

Findings:

Review of La R.S. 40:2009.20 revealed the following:
A. As used in this Section, the following terms shall mean:
(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.
B.(1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department....

Review of the hospital policy titled, "Adult Abuse/Neglect, Alleged or Suspected Abuse", Policy A.1.07, revealed Passive Neglect was defined as the deprivation, by the caregiver, of goods or services which are necessary to maintain physical or mental health, without a conscious attempt to inflict physical or emotional stress. Examples of passive neglect included evidence of poor care, poor skin hygiene, urine burns or excoriaiton. Additional review revealed all instances of suspected or identified abuse or neglect within the program (by program/hospital staff) should be immediately reported to the staff member's immediate supervisor, Chief Clinical Officer or designee, The Medical Director, and the Administrator. The policy revealed the patient should be assessed immediately and any findings should be documented in the medical record. The policy also revealed all instances of suspected abuse or neglect (whether internal or external to the program) would be investigated and the Corporate Risk Manager or designee would notify the Louisiana Department of Health according to the regulations.

Review of a complaint/grievance report dated 05/02/2019 at 9:30 p.m. revealed Patient #21 was reportedly found, by her caregiver, with the Foley catheter bag hanging on the bedrail, soaked in urine from chest to knees with puddling of urine between her legs. The caregiver also reported the patient had a bowel movement that had not been cleaned and she smelled very strongly of urine. The caregiver had reported she thought the catheter had leaked on the floor.

Further review of the incident report documentation revealed S3RN, Patient #21's primary nurse, had discussed the complaint with the sitter. Staff apologized for the incident and assured sitter frequent rounds would continue and the complaint would be written up and reported.

Additional review revealed S1CCO had been notified of the complaint by the charge nurse the next morning. S1CCO documented she had apologized to the family and assured the family involved staff would be educated. She indicated the family had requested concerns should be discussed with them and not the sitter in the future. Staff was educated regarding failure to establish procedures.

Further review of the incident report revealed no documented evidence of notification of LDH of the alleged neglect of care involving Patient #21 within 24 hours of discovery.

In an interview on 02/05/2020 at 7:50 a.m. with S1CCO, she confirmed she had not reported the incident involving Patient #21 as alleged neglect of care to LDH within 24 hours of discovery. She indicated she had spoken to the patient's family and had not spoken to the sitter, who had reported the incident, because the family had told her they wanted the hospital to communicate with them, not the sitter. S1CCO confirmed she had talked to the staff involved and had educated the staff regarding purposeful rounding. She indicated she had felt the issue had been resolved and had considered it a complaint and not a grievance.

Based on record review and interview, the hospital failed to ensure all patient records included documentation of the patient's care during hospitalization, outcomes of hospitalization, and disposition of care. This deficient practice was evidenced by failing to ensure the treating licensed practitioner completed a discharge summary for 2 (#17, #18 ) of 2 sampled transferred patient records reviewed from a total patient sample 30.

Findings:

Review of the Medical Staff By-laws revealed in part, Discharge summary: A discharge summary shall be recorded at the time of discharge unless awaiting test results. Any patient that dies in the hospital shall have a recorded death summary... A clinical discharge summary shall be included in the medical record of all patients except those that stay twenty-four hours or less. The discharge summary should contain the following: Admitting Diagnoses, Discharge Diagnoses, reason for hospitalization, Hospital Course, significant findings, procedures performed, care, treatment, and services provided. Instructions given to the patient and family at discharge, and the patient's condition at discharge.

Review of the hospital policy titled,"Physician Chart Deficiency Notification", Policy F.6.18, revealed in part: As per Medical Staff Bylaws, State, Federal, and The Joint Commission Standards, medical records must be completed within 30 days of discharge or the medical record becomes delinquent.

Patient #17
Review of Patient #17's medical record revealed the patient was admitted on 06/13/2019 and was transferred to a higher level of care on 06/22/2019. Patient #17 did not return to this hospital. Further review revealed there was no discharge summary documented in the patient's medical record as of 02/04/2020 (date of the medical record review).

Patient #18
Review of Patient #18's medical record revealed the patient was admitted on 08/25/2019 and was transferred to a higher level of care on 09/06/2019. Patient #18 did not return to this hospital. Further review revealed there was no discharge summary documented in the patient's medical record as of 02/04/2020 (date of the medical record review).

In an interview on 02/04/2020 at 2:17 p.m. with S2HIM, she confirmed, after review of Patient #17 and Patient #18's medical records, that there were no discharge summaries in the referenced closed records as of 02/04/2020.

Based on record review, and interview the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the crash cart was checked daily for availability and function of equipment, supplies, and drugs, as evidenced by missing entries on the daily crash cart logs.

Findings:

A review of Hospital Policy K.11.46 Crash Cart revealed in part:
1. Nursing/ Respiratory Responsibilities
A. Crash cart is to be checked by a nurse or respiratory therapist as assigned, every day to ascertain that the crash cart is secured and the defibrillator is charged and in proper working condition, the suction equipment operational and oxygen tank is full.

On 02/03/2020 at 8:35 a.m. a review of the crash cart check list failed to reveal documentation the checks were done on 01/11/2020 and 01/19/ 2020.

On 02/03/2020 at 8:35 a.m. in an interview S1CCO verified the above dates failed to have documentation the crash cart was checked. She also confirmed the staff are required to document the crash cart checks daily.

Based on policy review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices. This deficient practice is evidenced by: 1) failure to ensure expired supplies were not available for patient use; and
2) failure to ensure bottled water and nutritional supplements were dated and timed when opened and food that was expired/contained in compromised packaging was not available for patient consumption, and failure to ensure staff drink items were not stored with patient food items.

Findings:

1) Failure to ensure expired supplies were not available for patient use.

Review of the hospital's policy for Stock Rotation revealed in part, all stock items will be stored using the rotation system and the oldest product will be issued first... any items noted to have an expiration date will be pulled from stock before the expiration date and discarded.

The following items were observed on 02/03/2020 at 9:30 a.m. in the central supply room.
16 red vacutainers with expiration dates of 10/31/2019.
35 blue vacutainers with expiration dates of 01/14/2020.
3- 4 oz. bottles of Dyna-hex 4 solution, with an expiration date of 11/2019 for 3 bottles and an expiration date for one bottle of 8/2019.
5 Silversorb gel 1.5 oz. tubes - 1 tube with an expiration date of 9/2018 and 4 tubes with an expiration date of 7/2018.
4 -4 oz. bottles of PVP Prep solution with expiration dates of 5/19.

An interview was conducted with S1CCO on 02/03/2020 at 9: 30 a.m. S1CCO confirmed the above items were expired and should have been discarded.

2) Failure to ensure bottled water and nutritional supplements were dated and timed when opened and food that was expired/contained in compromised packaging was not available for patient consumption.

The following items were observed on 02/03/2020 at 9:50 a.m. in the patient nutritional storage room.

1 gallon plastic water bottle, opened and not dated;
1 can of Nestle's Resource Nutrtitional Thickening Powder, opened and not dated;
1 can of soup with both sides of the can indented towards the middle of the can, possibly compromising the contents of the can;
1 refrigerated sliced turkey and cheese sandwich, dated 01/31/2020 (should have been discarded on 02/01/2020- good for 2 days);
3 cans of Red Bull carbonated energy drink (for staff use and not patient use) in patient refrigerator;
1- 16 ounce package of miniature marshmellows, opened, not dated.

In an interview on 02/03/2020 at 10:05 a.m. with S1CCO, she confirmed the above referenced findings in the patient nutritional storage room.







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