HospitalInspections.org

Based on review of documents and staff interview it was determined the governing body failed to be responsible for an effective operation of the grievance process as evidenced by a failure to document the review and/or analysis of two (2) of two (2) grievances which were received in April 2012. This failure creates the potential for the quality of care for all patients to be negatively impacted.

Findings include:

1. At 0830 on 11/5/12 the Director of Quality/Risk provided two (2) grievance files for review. She stated these two (2) were the only grievances filed in the past several months. Review of these two (2) grievance files revealed one was dated 4/18/12 and the other was dated 4/26/12. Both grievances included allegations of significant patient care and treatment issues. Both files included only a report of the allegations/grievance and a letter to the complainant.

Neither file included any documentation of the steps taken to investigate the allegations, conclusions made as a result of the investigation or any resulting actions taken.

2. The policy "Patient and Customer Complaint or Grievance," last reviewed 11/6/12, was provided for review. It states in part: "The hospital must review, investigate and resolve each patient's complaint/grievance...The investigation into the complaint and the appropriate follow up actions will continue until the time of resolution...Hospital Risk Management will followup with departmental supervisor for action taken regarding employee issues if indicated...The Hospital should make sure that it is responding to the substance of each complaint/grievance while identifying, investigating and resolving any deeper, systemic problems indicated by the grievance."

3. These findings were reviewed and discussed with the Director of Quality/Risk. She provided a blank Complaint Investigation Summary form, last revised 8/09. She stated this form had been used in the past to document the steps taken to investigate complaints/grievances. Review of the form revealed the format included a place for findings/result of complaint and actions taken. The Director acknowledged this form was not used and this information was not recorded or included in the files for these two (2) grievances.

A. Based on review of medical records, policy and staff interview it was determined the registered nurse (RN) failed to reassess pain per policy for five (5) of six (6) patients reviewed who were assessed to be experiencing pain at the time of admission (patients #1, 2, 5, 8, 10). This failure creates the potential for the condition of all patients who are experiencing pain to be adversely impacted.

Findings include:

1. Review of the admission assessment for patient #1, completed by the registered nurse (RN) at 1830 on 8/3/12, revealed the patient reported pain, rated as a ten (10) on a 0-10 scale. The record revealed the patient received pain medication scheduled every four (4) hours which began at 2000 on 8/3/12. The record reflected the patient's pain was not reassessed by the nurse until 0612 on 8/4/12, nearly twelve (12) hours after the patient's level ten (10) pain was first identified.

2. This record was reviewed and discussed with the Interim Director of Nursing (DON) at approximately 12 noon on 11/13/12. She acknowledged the record reflected the RN failed to document a reassessment of the patient's pain level. The DON stated nursing staff is expected to assess for pain during hourly rounds or every time staff have patient contact. She stated the nurse is expected to record the patient's pain level, at time of assessment, on the Interdisciplinary Daily Nursing Assessment and/or Daily Flowsheet/Treatment Record. The DON stated the nurse should check orders to see what interventions are available for pain relief and administer/provide pain relief interventions as needed. She noted the nurse should continue to reassess pain levels for relief. She stated the nurse is to reassess patients within the hour for relief when pain medications are administered.

3. The "Interdisciplinary Daily Documentation," policy, last revised 1/09, was provided for review. It states in part: "Purpose: To document patient assessments and reassessments, care provided, response to care, and functional performance and status in an interdisciplinary manner, depicting the fulfillment of the patient's rehabilitation needs...The Pain section should record the pain assessment conducted at the time of the full assessment. The absence of pain should be recorded as '0', not left blank. Additional pain assessments are located throughout the daily documentation of the clinical staff."

The "Pain Management, Assessment, Care and Documentation," policy, last revised 7/05, was provided for review. It states in part: "Uncontrolled pain is pain that is rated greater than four (4) on the 0-10 pain scale in a four (4) hour period at rest or any pain rated greater than four (4) on the 0-10 scale reported twice in a 24 hour period of time with activity...With each episode of pain, all areas on the HealthSouth Flow Sheet will be documented...With each episode of pain, have the patient rate the intensity of pain, utilizing the pain rating scale 1-10."

4. Review of the Daily Flowsheet/Treatment Record form revealed the Pain section has five (5) sections for the nurse to complete: Pain Location, Initial Pain Scale, Description, Intervention and Reassessed Pain Scale.

5. Review of the admission assessment for patient #2, completed by the RN at 2100 on 8/16/12, revealed the patient reported pain rated as a four (4) on a 0-10 scale. At 2330 the nurse documented she medicated the patient for "out of control" pain. The record reflected the patient's pain was not reassessed by the nurse until 0700 on on 8/17/12 at which time the patient reported pain rated as a ten (10) on a 0-10 scale.

6. Review of the admission assessment for patient #5, completed by the RN at 1920 on 11/5/12 revealed the patient reported pain rated as a nine (9) on a 0-10 scale. At 2100 the nurse documented the patient "wants pain pill around bedtime." Review of the record revealed the patient's pain was not reassessed until 2400. The patient's medication administration record revealed the patient did not receive pain medication until 11/6/12 at 1530.

These records were reviewed and discussed with the Interim DON at 1400 on 11/14/12. She agreed with these findings.

7. Review of the admission assessment for patient #8, completed by the RN at 2020 on 11/5/12 revealed the patient reported pain rated as a five (5) on a 0-10 scale. At 2110 the nurse documented the patient reported pain rated as a six (6) and was medicated with a pain pill. No reassessment of the patient's pain was documented following administration of the medication.

This record was reviewed and discussed with the Interim DON at 1450 on 11/14/12. She agreed with these findings.

8. Review of the admission assessment for patient #10, completed by the RN at 1700 on 11/1/12 revealed the patient reported pain rated as a four (4) on a 0-10 scale. No reassessment of the patient's pain was documented on 11/1/12. Review of the medication administration record revealed the patient was first medicated for pain at 0023. Review of the Daily Flowsheet/Treatment Record revealed the patient's pain/medication effectiveness was not reassessed.

This record was reviewed and discussed with the Interim DON at 1515 on 11/14/12. She agreed with these findings.

B. Based on review of the medical record, policy and staff interview it was determined the registered nurse (RN) failed to re-evaluate the condition of one (1) of one (1) current patients reviewed (patient #4) who became disoriented during therapy. This failure creates the potential for all patients who experience a change in condition to be adversely impacted.

Findings include:

1. Review of the medical record for patient #4 revealed Nursing Supervisor #1 documented in part at 1345 on 11/13/12: "...patient became disoriented and stiff...Blood pressure 103/57, Pulse 63, Respirations 18, Oxygen Saturation 93% and Blood Sugar 288 (Normal range 68 - 99).

Nursing Supervisor #1 documented in part at 1400 on 11/13/12: "...patient states 'back of head hurts, is a two (2) and happens frequently when sitting up for long periods of time."

2. The record lacked documentation to reflect the patient was re-assessed by the nurse during the next four (4) hours and forty (40) minutes. At 1840 the Rehab Nursing Technician documented in part: "walked by patient room, seen patient on floor crawling and blood on floor from where patient busted open elbows..."

3. At 1010 on 11/14/12 these notes were reviewed with Nursing Supervisor #1. The lack of nursing reassessment of the patient was discussed. She stated the nurse who went in to catheterize the patient should have documented the assessment. The Nursing Supervisor stated that when she went into the patient's room to tell him about notifying his daughter of his earlier episode of disorientation that the patient told her he was having difficulty emptying his bladder. She stated she told Licensed Practical Nurse (LPN) #1 about the patient's urinary difficulty. Review of the record with the Nursing Supervisor revealed no documentation related to the patient's urinary difficulty and no documentation to reflect the patient was reassessed by the RN prior to being found crawling on the floor.

3. The policy "Emergency Appraisals, Initial Treatment, and Referral for additional services," last revised 2/19/10, was provided for review. The policy states in part: "In most instances, clinical staff within our hospital will be able to prevent and manage complications through early recognition of symptoms and quick intervention...Identified changes in patient's condition result in additional assessments performed by the RN to determine an appropriate response..."

4. These findings were reviewed and discussed with the Interim Director of Nursing at 1025 on 10/14/12. She agreed the record lacked documentation to reflect the patient was reassessed by the RN as expected.

C. Based on medical record review, review of policy and staff interview it was determined the registered nurse (RN) failed to supervise and evaluate patient care. The RN failed to report a change of patient condition to the physician for one (1) of three (3) acute care transfers reviewed (patient #4). This failure creates the potential for a delay in medical care which can adversely impact the outcome for all patients who experience a change of condition.

Findings include:

1. At approximately 1340 on 11/13/12 an overhead "Dr Stat" page was heard to be called in the Physical Therapy Gym. Licensed Practical Nurse (LPN) #1 who was being interviewed, responded to the page. The Interim Director of Nursing (DON), noted this page may involve one of the LPN's patients and stated this page indicated a potential clinical situation with a patient in the therapy department that required immediate assessment and/or intervention.

2. Review of the daily nursing assessment for patient #4 revealed the patient was assessed by the RN as alert and oriented to person, place, time and situation at 0710 on 11/13/12.

3. At 1345 on 11/13/12 Nursing Supervisor #1 documented: "While ambulating in Physical Therapy gym, patient became disoriented and stiff...Blood pressure 103/57, Pulse 63, Respirations 18, Oxygen Saturation 93% and Blood Sugar 288." (Normal range 68-99)

4. At 1400 on 11/13/12 Nursing Supervisor #1 documented in part: "...patient states back of neck hurts is a two..." (pain level rated as a two (2) on a 0-10 scale)

5. The record revealed no documentation the RN notified the physician when a stat page was called regarding the patient's episode of disorientation, becoming 'stiff' and elevated blood sugar level.

6. At 1840 the Rehab Nursing Technician documented in part: "Walked by patient room, seen patient on floor crawling and blood on floor from where patient busted open elbows...patient then tried to hit me on my legs and screaming 'I have to get out of here.' ...Patient was swinging arms, kicking feet, screaming, trying to bite staff members, using curse words and also trying to scoot away from us. Took 4 of us staff members to hold him down for his safety."

7. The record reflected the patient was transferred out to a acute care facility at 1930 for increased level of consciousness (?) and combativeness On 11/14/12 at 0300 the Nurse documented the patient was admitted to the outside facility with diagnosis of Sepsis and Urinary Tract Infection.

8. Interview was conducted with Nursing Supervisor #1 at 1010 on 11/14/12. Her note related to the patient becoming disoriented and stiff with an elevated blood sugar reading was discussed. The lack of documentation of a physician notification related to the patient's change of condition was also discussed. She confirmed the physician was not made aware of the incident.

9. The policy "Emergency Appraisals, Initial Treatment, and Referral for additional services," last revised 2/19/10, was provided for review. The policy states in part: "Identified changes in patient's condition result in additional assessments performed by the RN to determine an appropriate response...If an urgent or potentially life threatening situation is identified, a physician is immediately contacted for medical direction..."

10. This record was reviewed and discussed with the Interim DON at 1025 on 11/14/12. She agreed the physician should have been promptly notified of the patient's change in condition.