HospitalInspections.org

Based on review of hospital documents, surveyor observations and interviews with staff, the hospital failed to ensure patients/patients' representatives are informed whom to contact to file a grievance and to notify patients/patients' representatives that they have the right to file a grievance with the State agency.

Findings:

1. The Patient Right's Policy provided to the surveyors by the administrator contained information on whom to contact to file a grievance and how to file a grievance with the State Agency. The Patient's Rights handout given to the surveyors by the administrator on the morning of 06/22/2010 did not contain information to inform patients/patients' representatives of the above information.

2. The surveyors asked the Chief Nursing Officer (CNO) how a patient would file a grievance and if the patient was given any other information concerning filing grievances or complaints. The CNO confirmed no other information is provided to patients. This was also confirmed with the Administrator.


3. These findings were discussed with the administrator and the CNO on the morning of 06/22/2010 when the patient rights handout was provided and again at the exit conference on the afternoon of the same day.

Based on review of policies and procedures and medical records and interviews, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In six of six patient records reviewed, the nurse did not perform complete assessments so that care needs could be identified and did not supervise nursing staff to ensure accuracy and completeness of documentation.

Findings:

1. On 06/22/2010, the Chief Nursing Officer (CNO) told the surveyors that RN assessments were to be performed at least once in a 24 hour period and an RN was expected to perform the initial nursing assessment on inpatients and same day surgery patients. The registered nurse did not perform complete nursing assessments for 8 of 8 patient records reviewed so that patient needs could be identified and did not supervise nursing staff to ensure the accuracy and completeness of documentation. The patient mentioned in the complaint's chart did not have a complete nursing assessment.

2. A "personal care" documentation section of the daily flowsheet was provided for nursing to document daily hygiene, ambulation and assistance activities of the patient. In four of four inpatient charts (1,3,5,7) documentation in the "personal care" section was left blank. The patient (#1) mentioned in the complaint's chart did not have any documentation in the "personal care" section of the chart. There was no documentation of daily care, ambulation, or assistance in the nursing narrative.

3. A patient education document was provided for nursing to document patient's orientation to room, call light, and other equipment provided in the room. In two of four (1,5) inpatient charts documentation in this section was left blank. The patient mentioned in the complaint did not have documentation in the chart indicating orientation to the room, call light, and equipment.

4. Six abdominal surgery patient's charts were reviewed. Three ( 2,4,8) were same day surgery patients, two (1,5) had overnight stays.
4.a. 3 of 3 same day surgery patient's who had the same procedures received discharge instructions based on their surgical procedure.

4.b. 2 of 2 overnight stays had discharge instructions that did not correspond to the patient's diagnosis or procedure. There was no discharge instruction provided to patients on postoperative care of surgical site, postoperative ambulation, postoperative diet, or use of pain medication.

4.c. The patient (#1) mentioned in the complaint did not have discharge instructions based on the surgical procedure. Patient #1's discharge instructions in the chart were signed " Dr.F/ Staff C" where the signature line indicated "patient signature". There was no documentation of the patient's discharge, discharge instruction, or receipt of discharge instruction in the nursing narrative notes.

5. On the afternoon of 6/22/2010 these findings were reviewed with the Administrator and CNO.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Chief Nursing Officer, or designee, provided orientation and evaluation of agency nursing personnel. This occurred for one of one agency personnel requested for review.

Findings:

1. The surveyors requested five personnel records (A,B,C, D, E). One personnel record Staff E was agency nursing personnel. The records provided to surveyors the afternoon of 6/22/2010 contained information from the agency. There was no documentation provided in the agency nursing personnel record the hospital had oriented, trained, or evaluated care provided by the agency nurse.

2. This finding was reviewed with the Chief Nursing Officer and Administrator on the afternoon of 6/22/2010. No further information was provided.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:

1. Four of four (1,3,5,7) inpatient records had incomplete initial nursing assessments.
1. a. Four of four inpatient records did not have skin assessments completed.
1. b. Four of four inpatient records did not have falls risk assessment completed.
1. c. Four of four inpatient records nutritional screens were not complete.
1. d. Four of four inpatient records documentation in the "personal care" section were not complete.

2. Eight of Eight (1,2,3,4,5,6,7,8) did not have post anesthesia care unit (PACU) orders noted

3. Record #6 did not have documentation of intravenous therapy initiation, site selected, type of cather, type of fluid, or care of site. Documentation was provided as to removal of the intravenous cather after a surgical procedure. There was no documentation of the type or amount of fluid infused.

4. Record #1 did not have documentation of patient condition or disposition upon leaving the post anesthesia care unit (PACU). Last narrative started in (PACU) flowsheet was an "arrow pointing downward pain" no other words or symbols were documented. There are no other documents in the chart indicating what occurred with the patient during the remainder of the stay in the PACU.

5. Record #1 last narrative documented dated 9/9/09 states "foley dic'd @ 0945". There is no other documentation in the flowsheet or narrative regarding patient status, activities, ability to void, discharge. There are no other documents in the chart indicating what occurred with patient after 0945.

6. Six abdominal surgery patient's charts were reviewed. Three ( 2,4,8) were same day surgery patients, two (1,5) had overnight stays.
6a. 3 of 3 same day surgery patient's who had the same procedures received discharge instructions based on their surgical procedure.

6.b. 2 of 2 overnight stays had discharge instructions that did not correspond to the patient's diagnosis or procedure. There was no discharge instruction provided to patients on postoperative care of surgical site, postoperative ambulation, postoperative diet, or use of pain medication.

6.c. The patient (#1) mentioned in the complaint did not have discharge instructions based on the surgical procedure. Patient #1's discharge instructions in the chart were signed " Dr.F/ Staff C" where the signature line indicated "patient signature". There was no documentation of the patient's discharge, discharge instruction, or receipt of discharge instruction in the nursing narrative notes.

7. On the afternoon of 6/22/2010 these findings were reviewed with the Administrator and CNO.