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Based on record reviews and interviews, the hospital failed to implement its grievance procedure in accordance with hospital policy as evidenced by failure to have documented evidence that the grievance was escalated to the Chief Nursing Officer or Medical Staff Leader when the Patient Relations Department did not receive written response of findings within 3 business days from the Hospital Manager investigating the complaint and failure of the Manager to have documented evidence of the investigation conducted for 1 (#1) of 2 grievances reviewed.
Findings:

Review of the hospital policy titled "Patient Grievance Management", presented as a current policy by S8Director, revealed when an issue/concern cannot be promptly resolved (Grievance), the Patient Relations representative will initiate the grievance process by entering the data into the electronic tracking system and will send out an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process. The Patient Relations Department will immediately forward a copy of the grievance to the appropriate investigators (Hospital Manager/Director or Physician) by electronic mail. Upon the investigator's receipt of the grievance, an investigation will begin within 1 business day to address the specific issues/concerns that were communicated by the patient/family. Written response of findings from the investigators will be sent via electronic mail to the Patient Relations department within 3 business days. If the response is not received from the investigators within 3 business days, the grievance will be escalated to the Chief Nursing Officer or Medical Staff Leader, or their delegate, for resolution and written response within 3 business days of their receipt. A written resolution letter will be sent to the patient that addresses the substance of each complaint made, and will also contain the results of the grievance process.

Review of the "Current Summary" of Patient #1's mother's grievance, presented by S8Director, revealed the grievance was received by the Patient Relations Department on 02/08/16 at 1:11 p.m. The grievance was sent by internal memo from S16PR on 02/10/16 at 8:36 a.m. to S4RN, and a 7 day letter was mailed to Patient #1's mother at that time. Further review revealed an internal memo was sent by S16PR to S4RN on 02/17/16 at 9:10 a.m. requesting "work done on file" (2 business days after it was due from S4RN). Response from S4RN to S16PR was documented on 02/24/16 at 11:52 a.m. (7 business days after it was originally due from S4RN). There was no documented evidence the grievance was sent to the Chief Nursing Officer of Medical Staff Leader, or their delegate, for resolution after it was not received from S4RN within 3 business days as required by hospital policy.

Review of S4RN's response of her investigation to S16PR on 02/24/16 at 11:52 a.m. revealed "in receiving a statement from (name of charge nurse), the call bell was falsely alarming in which she explained that she would place a work order in to remedy the false alarming..."

In an interview on 05/04/16 at 9:20 a.m. with S15PR and S16PR present, S16PR confirmed the documentation of the grievance process related to the grievance submitted by Patient #1's mother was complete, and grievance was not forwarded to anyone when documentation from S4RN was not received within 3 business days.

In an interview on 05/04/16 at 9:45 a.m., S4RN indicated she had interviewed staff nurses who provided care to Patient #1 and the charge nurse and had reviewed his medical record as part of the investigation of the grievance. She further indicated she had not documented any of the investigation and interviews conducted. She confirmed she didn't have documentation to present of her investigation of Patient #1's mother's grievance.

Based on record reviews and interviews, the hospital failed to ensure the written notice of its decision provided to patients contained the results of the grievance process as evidenced by failure to have the outcome of the investigation of each complaint voiced in the grievance addressed in the letter for 2 (#1, #2) of 2 patient grievances reviewed.
Findings:

Review of the hospital policy titled "Patient Grievance Management", presented as a current policy by S8Director, revealed when an issue/concern cannot be promptly resolved (Grievance), the Patient Relations representative will initiate the grievance process by entering the data into the electronic tracking system and will send out an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process. The Patient Relations Department will immediately forward a copy of the grievance to the appropriate investigators (Hospital manager/Director or Physician) by electronic mail. Upon the investigator's receipt of the grievance, an investigation will begin within 1 business day to address the specific issues/concerns that were communicated by the patient/family. A written resolution letter will be sent to the patient that addresses the substance of each complaint made, and will also contain the results of the grievance process.

Patient #1
Review of Patient #1's mother's grievance received by the Patient Relations department on 02/08/16 revealed the following complaints: her son signed a discharge appeal, and his copy was stolen from his room by a nurse which caused him to be discharged on Saturday and not the following Monday like he requested; she is waiting on the coroner's report and stated her son's cancer diagnosis is incorrect and that he actually died from asbestos poisoning and that it's "a cover up"; while her son was in the hospital the charge nurse stated she wouldn't respond to the call and stated her son's mistreatment was race-related and he was discharged with a bedsore and without oxygen.

Review of documentation presented by S8Director revealed Patient #1 signed with initials on 01/15/16 at 11:10 a.m. a form to appeal his discharge that was sent to Company A on 01/15/16. Review of documentation by the case manager on 01/16/16 at 11:25 a.m. revealed the case manager spoke with a representative of Company A who stated they had reviewed Patient #1's discharge appeal and determined Patient #1 was ready for discharge and had until 12:00 p.m. 01/17/16 to be discharged. Company A's representative reported to the case manager that she (Company A representative) had attempted to call Patient #1's mother, who filed the appeal on her son's behalf, but the first time Patient #1's mother hung up on the representative. When the representative attempted follow-up calls, the phone calls were not answered, and Patient #1's voice mail box was full. Further review of documentation by the case manager revealed at 11:30 a.m., she spoke with Patient #1 at his bedside and advised him that he had lost his discharge appeal. Patient #1 at that time indicated his cousin was here, and he was ready to go home. Arrangements were made to discharge Patient #1 on 01/16/16.

Review of S4RN's response of her investigation to S16PR on 02/24/16 at 11:52 a.m. revealed "in receiving a statement from (name of charge nurse), the call bell was falsely alarming in which she explained that she would place a work order in to remedy the false alarming. The patient's mother in turned might have mistakenly perceived that it was a refusal to respond to the alarm. The patient was not mistreated due to race as we don discriminate, and oxygen is typically not utilized for hospice transportation. I did not see a bedsore listed for this patient while completing a chart review."

Review of the resolution letter sent to Patient #1's mother dated 02/25/16 and signed by S4RN revealed the following:
"This letter is to advise that we have undertaken and completed a review of the concerns you presented. This review included a medical record review, as well as discussions with the staff involved in your son's care. You shared how you felt the nurses on the 9th floor, Medical Surgical Unit (MSU) did not provide a thorough explanation surrounding his discharge. We apologize for any discomfort or concern this incident has caused and thank you for bringing this matter to our attention..." There was no documented evidence that the discharge appeal process and responses from Company A were addressed in the resolution letter. Further review of the resolution letter revealed "You also shared how you felt our employees you encountered on MSU were unhelpful when you were pressing the call light. Please know that the staff involved in your care have been made aware of your concerns and the importance of responding to all patient calls in a timely, compassionate manner has been reinforced..." There was no documented evidence that Patient #1's mother's response letter addressed the information received from the charge nurse about the call light, the questionable diagnosis of Patient #1, and being discharged with a bedsore and without oxygen.

In an interview on 05/04/16 at 9:20 a.m. with S15PR and S16PR present, S16PR indicated Patient #1's mother complained by telephone on 02/08/16. She further indicated the initial resolution letter was not received by Patient #1's mother, because the address had changed. When Patient #1's mother reported on 03/21/16 that she didn't receive the letter, the resolution letter was resent to her. During the interview a request was made by the surveyor of the evidence that the resolution letter was resent. Both S15PR and S16PR confirmed the resolution letter sent to Patient #1's mother did not address all the complaints voiced in the initial grievance report. They indicated they did not have any documentation of the investigation conducted by S4RN.

No further evidence that the resolution was resent to Patient #1's mother was provided as of the time of exit on 05/04/16 at 5:40 p.m.

In an interview on 05/04/16 at 9:45 a.m., S4RN confirmed the resolution letter did not include information about all the complaints voiced by Patient #1's mother in her grievance. She indicated when she documented that Patient #1 didn't have a bedsore, she meant that he it wasn't a hospital-acquired bedsore. When informed that the medical record review revealed Patient #1 did not have a decubitus upon admit, she had no explanation to offer.

Patient #2
Review of Patient #1's mother's grievance, received by the Patient Relations Department on 02/22/16, revealed the deceased patient's wife complained that Patient #2 was severely impacted and in a lot of pain, and Patient #2 used the oral suction device to disimpact himself; the nursing staff did not respond to the call light in a timely manner on the day and night shifts.

Review of the resolution letter sent to the complainant for Patient #2, dated 03/18/16, revealed the following, in part: ..."This letter is to advise that we have undertaken and completed a review of the concerns you presented. This review included a medical record review, as well as discussions with the staff involved in your husband's care. You shared how you felt our employees you encountered on the Medical Surgical Unit were unhelpful when you or your family were pressing the call light. Please know that the staff involved in your husband's care have been made aware of your concerns and the importance of responding to all patient calls in a timely, compassionate manner has been reinforced. Please be assured we are currently in the process of hardwiring purposeful hourly rounding to all of our patients and have used your feedback to support the purpose of this initiative to staff. This new process should not only assist in decreasing the number of call lights in an effort to get in touch with staff, but should also make our patient stay more comfortable one..." The author of the letter was S4RN.

In an interview on 05/04/16 at 1:15 p.m., S16PR indicated they had received the complaint from Patient #2's wife on 02/22/16 via a telephone call, and subsequently began the Grievance Process. She confirmed the grievance was considered closed on 03/18/16 with the completion and forwarding of the resolution letter by S4RN. Upon reviewing the resolution letter with the surveyor, S16PR agreed that the resolution letter did not address all of the complainant's concerns, including the complainant's major issue, which was constipation and subsequent fecal impaction the patient attempted to remove himself utilizing an oral suction device.

In an interview on 05/04/16 at 1:30 p.m., S15PR indicated there was no current tracking and/or documenting of the appropriateness and completeness of the resolution letter submitted to the complainant by the assigned investigator. S15PR confirmed the grievance process, and the grievance policy and procedure, had not been followed, and it should have been.



31048

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having nurse call lights on the hand rails of patient beds on the 9th floor Medical-Surgical Unit not functioning for 25 of 52 beds located on the 9th floor Medical-Surgical Unit. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the call light on the bed hand rail rather than the hand held call light.
Findings:

Observation on 05/02/16 at 11:20 a.m. of rooms on the North and West wings of the 9th floor Medical-Surgical Unit revealed patient beds with the nurse call bell on the side rail not functioning, either due to the wall connection to the bed connection not being attached, the wall connection and bed connection connected but the call system not functioning, or having no wall and/or bed connection present, in Rooms a, b, c, d, e, f, g, h, i, and j.

In an interview on 05/02/16 at 11:40 a.m., the daughter of Patient R3, who was in Room "k," indicated they were told to use the hand held call light, because the call light on the bed hand rail did not work.

In an interview on 05/02/16 at 12:03 p.m., Patient R4, who was in Room "h," indicated she was instructed to use the hand held call light, and if it was not working, to use the call light button on the bed hand rail.

Observation on 05/02/16 at 11:20 a.m. of rooms on the South and East wings of the 9th floor Medical-Surgical Unit revealed patient beds with the nurse call bell on the side rail not functioning, either due to the wall connection to the bed connection not being attached, the wall connection and bed connection connected but the call system not functioning, or having no wall and/or bed connection present, in Rooms l, m, n, o, p, q, r, s, t, u, v, w, x, and y.

In an interview on 05/02/16 at 11:35 a.m., S5RN indicated patients communicate their need for assistance by use of an electronic call light system. She indicated the bed rails have a call button for use, and each patient has a hand-held call button for use. She also indicated they "encourage the patients to use the hand-held call light."



31048

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 the RN assessed and staged and reassessed patients' wounds/decubitus and performed wound care in accordance with hospital policy and physician orders for 3 (#1, #4, #5) of 4 patient records reviewed with wounds from a total sample of 5 patients. 2) Failing to ensure the RN assessed and reassessed the elimination status of 2 (#2, #4) of 5 patient records reviewed with elimination problems from a total sample of 5 patients. Findings:
Review of the hospital policy titled "Assessment and Reassessment (Hospitalized Patients)", presented as a current policy by S8Director, revealed that upon admission to the unit, a RN will assess each patient to collect data, determine any immediate needs, and make appropriate care assignments. The patient is reassessed as necessary based on his/her plan of care for changes in his/her condition. Patients will be assessed when a significant change in the patient ' s condition occurs and in response to intervention. Essential elements of the reassessment include focused physical system review based on the medical diagnosis.
1) Failing to ensure the RN assessed and staged and reassessed patients' wounds/decubitus and performed wound care in accordance with hospital policy and physician orders: Review of the hospital policy titled "Nursing Clinical Practice Guidelines", presented as a current policy by S8Director, revealed the hospital will use primarily four types of clinical nursing standards that include the following: 1) Clinical procedures in the approved Mosby's Skills procedures and hospital-developed procedures; 2) Clinical Practice Guidelines Approved Elsevier Clinical Practice Model guidelines; 3) Basic Care Guidelines; and 4) Clinical Interventions Guidelines of hospital-developed guidelines.
Review of the hospital policy titled "Patient Care Consults", presented as a current policy by S8Director, revealed a consult can be generated for select disciplines based on pre-established high risk criteria upon admission or periodically throughout the hospital stay. A notation is made in the computer and/or progress notes regarding assessment findings, recommendations, and follow-up needed. There was no documented evidence that the timeframe for completing the evaluation by the consultant was addressed and whether reassessment by the wound care nurse had to be done after the initial assessment.
Review of "Pressure Ulcer Prevention and Treatment", presented by S8Director as the resource from Elsevier Clinical Practice Model guidelines used by the nursing staff for assessing, reassessing, and documenting pressure wounds and staging, revealed that a suspected DTI was defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further review revealed a through nursing assessment should be completed upon admit that includes all skin surfaces. The skin should be assessed at least daily and more often if abnormalities are identified, noting skin alteration changes. When an ulcer is identified, the stage of the ulcer should be determined with an assessment of the location, size on initial assessment and at least weekly, and on discharge (use centimeters to document length, width, and depth). The condition of the dressing should be assessed at least once a shift. At the time of dressing change, the character of and amount of drainage should be assessed and the presence or absence of odor.
Review of "Skin Integrity Impairment, Risk / Actual", presented by S8Director presented by S8Director as the resource from Elsevier Clinical Practice Model guidelines used by the nursing staff for assessing, reassessing, and documenting arterial, venous, and diabetic ulcers, revealed that wound care management included the following: measure length, width, and depth of the affected area in centimeters weekly; note exudates or changes in wound characteristics, such as erythema, induration, maceration, odor, pain, correlating with dressing type and frequency; protect wounds from sources of shear and friction; avoid pressure on wound; outline specific skin care treatment on the plan of care including doctor ' s orders.
Patient #1 Review of Patient #1's medical record revealed he was admitted on 01/09/16 and discharged on 01/16/16. Review of his emergency department's nurse's note revealed his skin upon arrival was warm, with normal skin turgor, dry oral mucus membranes, and he had no rashes or lesions.
Review of Patient #1's "Discharge Summary" documented by S20MD on 01/16/16 at 1:27 p.m. revealed Patient #1 had a Stage II pressure ulcer, 7 cm in width with no depth noted, and black, discolored tissue beginning to shear and leaving a moist dark-red wound bed, partial thickness, and no drainage or odor noted.
Review of the nursing assessment documented during the hand-off from the emergency department to the inpatient nursing unit revealed Patient #1's skin was warm and dry with no documented evidence of wounds/pressure ulcer.
Review of Patient #1's medical record revealed the following assessments of his pressure ulcer identified on 01/11/16 at 10:00 a.m.: 01/11/16 at 10:00 a.m. by S22RN - Stage III, dressing dry, intact; small amount yellow/tan drainage; cleaned with soap and water; dressing changed, foam. There was no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/12/16 at 12:41 p.m. by S21RN - Stage III, small amount of yellow, tan drainage. There was no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/12/16 at 11:49 p.m. by S21RN - no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/13/16 at 8:09 a.m. by S18RN - Stage III with small amount yellow, tan drainage; cleaned with soap and water, barrier applied, Telfa island dressing applied. 01/13/16 at 8:30 p.m. by S21RN - Stage III scant blood-tinged drainage, reddened appearance, wound edges intact; 01/14/16 at 8:00 p.m. by S23RN - Stage III no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact; 01/16/16 at 8:22 a.m. by S19RN - Stage III, no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact, jagged; 01/16/16 at 12:07 p.m. by S19RN - Stage III, no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact, jagged. Braden Risk Assessments documented varied between 11 - 16.
In an interview on 05/03/16 at 1:30 p.m., S8Director indicated S23RN was no longer employed and thus was not available to be interviewed.
In an interview on 05/03/16 at 2:10 p.m. with S17RN, wound care nurse, and S24RN, Clinical Coordinator Wound Ostomy, present during interview, S17RN indicated he was a wound care nurse. After reviewing the documentation of his progress note documented when he conducted the physician-ordered wound care consult for Patient #1, S17RN indicated he remembered Patient 31. He further indicated he assessed the pressure ulcer as DTI, " because we don't know what stage it's going to be ... in process of changing." When asked about the policy's definition of DTI as intact skin and the photograph in the medical record revealing break in the skin, S24RN indicated it (DTI) starts as intact skin. S17RN indicated he categorized it as a DTI, because it's still evolving, and we don't know if it will be a Stage II, III, or IV. S17RN confirmed the initial assessment of Patient #1's wound by S22RN as Stage III was not accurate. S24RN indicated she doesn't think they have an official policy that addresses when they're to follow up with patient after the initial wound consult is conducted. She further indicated, as a wound nurse, she would have assessed Patient #1's pressure ulcer as a DTI and would not have staged it.
In an interview on 05/03/16 at 2:35 p.m. with S18RN and S4RN present, S18RN indicated she had generic training on wound assessment and staging that she completed online. She further indicated she remembered Patient #1. After review of her documentation of 01/13/16, S18RN indicated she determined the ulcer to be a Stage III by the size and amount of drainage and the redness of underlying tissue she saw. She further indicated she used the drop-down box available in the computerized medical record that describes the different stages and looked at pictures in Mosby's Skills to double-check what she thought it was. She indicated she didn't remember if she went to look at the wound care nurse's notes from day before. S18RN indicated she doesn't stage wounds often. She confirmed that's why she has to refer to a guide, because "it's not something I see every single day."
In an interview on 05/03/16 at 2:45 p.m. with S19RN and S4RN present, S19RN indicated she was hired in March 2016. She further indicated she had not been evaluated for competency for assessing and staging wounds/pressure ulcers since she was hired, but she had a competency evaluation when worked at the hospital as an agency nurse (review of competency evaluation revealed it was a self-assessment with no documented evidence of a competency evaluation by a hospital-employed RN). After reviewing her documentation on 01/16/16 with Stage III documented, S19RN indicated she remembered the patient. S19RN indicated if a wound was staged previously as a Stage III, it will always be a Stage III. She further indicated she won't "undo somebody's staging" , because she isn't certified. After asking again to clarify her answer, S19RN indicated if it's staged as a III, she will leave it that way until the wound care person stages it (wound care nurse documented his assessment on 01/12/16 prior to S19RN ' s assessment).
In a telephone interview on 05/03/16 at 3:15 p.m., S20MD indicated if he documented a pressure ulcer, he usually had wound pictures to look at, or he would have directly observed the wound. He confirmed that he does not review the documentation in the medical record by others to document wounds in the discharge summary.
In an interview on 05/04/16 at 7:55 a.m. with S21RN and S4RN present. When asked how she determined the stage of a pressure ulcer, she indicated she looks at the tool in the computer and the wound care nurse's documentation. She further indicated she had not had training in wound assessment and staging other than the online course. When asked what she's supposed to document when assessing wounds, S21RN answered diameter (depth, width), the wound itself, drainage and color, periwound, tunneling, and whether it's open or closed. After reviewing her documentation of Patient #1's pressure ulcer on 01/11/16, she was asked if her assessment included the above-mentioned items. She indicated it included drainage and location and indicated it did not include a full assessment in accordance with the hospital guidelines.
In an interview on 05/04/16 at 8:15 a.m., S8Director indicated Mosby's clinical intervention guidelines is what nurses have to follow for assessing and staging wounds. She confirmed the hospital's policy for consults doesn't address how soon the consult must be done after it's ordered and the frequency at which follow-up must be done by the wound care nurse.
In an interview on 05/04/16 at 8:55 a.m. with S22RN and S4RN present, S22RN indicated she has worked here about 1 year. During orientation she was taught to assess patients when they arrive to know if the patient has pre-existing wounds and to consult wound care if wounds are identified. She further indicated the preceptor goes over it with her when doing patient care and she has had online training, but she relies on the wound care nurse for assessment more than anything. She further indicated she's "not the best at staging and would document exactly what I see, such as color, drainage." S22RN indicated she wouldn't measure any wounds. After reviewing documentation of 01/11/16 as the 1st observer of Patient #1's wound, S22RN was asked how she determined it was a Stage III. She indicated she looked at how severe it looked and that it was reddened. She again indicated at that time (time of her documentation) "I was not very good with assessment of and staging wounds." S22RN indicated she didn't know the protocol for reassessment, measurement, and staging of wounds. Patient #4Review of the medical record for Patient #4 revealed he was a 67-year-old male admitted to the hospital on 04/27/16 with a diagnosis of Bilateral Lower Extremity Cellulitis.
Review of the EMR revealed on 04/29/16 at 3:20 p.m., an order for wound care was written: "Wound care routine: cleanse legs with Easicleanse wipes, pour 2 tubes of lotion on each leg and rub in the best you can, daily."

In an interview on 05/04/16 at 4:10 p.m., S11RNInfo reviewed the EMR with the surveyor and confirmed there was no documented evidence that the above-referenced wound care orders were implemented.

Patient #5 Review of Patient #5's medical record revealed he was admitted on 04/13/16 with a diagnosis of Peripheral Vascular Disease.
Review of Patient #5's physician orders revealed an order for a wound care consult on 04/13/16 at 11:05 p.m. Further review revealed an order on 04/16/16 at 2:45 p.m. and on 04/22/16 at 7:19 p.m. for daily wound care to the left lateral foot and medial dorsal left foot that included cleaning with Normal Saline, apply cavilon no sting barrier film to periwounds, apply medi-honey to wound beds and cover with dry gauze and secure with kerlix.
Review of patient #5's wound care evaluation conducted on 04/14/16 at 2:33 p.m. revealed wound to left lateral foot measured approximately 8 cm length by 3.5 cm width by 0.2 cm depth with moist pink tissue with 60% covered with yellow slough. There was no drainage or odor noted. Further review revealed the wound to the left medial dorsal foot measured approximately 4 cm length by 4 cm width by 02.cm depth with moist pink wound bed with 20% covered with yellow slough. The surrounding tissue had pink scarring. The wounds were cleansed with Normal Saline, cavilon no sting barrier film applied to periwounds, wounds dressed with medi-honey and dry gauze and secured with Kerlix. Recommendation was that nursing change the dressing daily.
Review of Patient #5's wound assessments revealed the following: 04/15/16 - no documented evidence wound care was performed; 04/17/16 - no documented evidence wound care was performed; 04/20/16 - no documented evidence wound care was performed; 04/21/16 - no documented evidence wound care was performed; 04/22/16 - no documented evidence wound care was performed to left medial dorsal foot; 04/27/16 - no documented evidence wound care was performed to left medial dorsal foot; No documented evidence wound care performed on 04/28/16 to left lateral foot on 04/29/16; No documented evidence wound care performed on 04/29/16, 05/01/16 to either wound and on 05/02/16 to the left lateral foot.
In an interview on 05/04/16 at 4:15 p.m. with S10RNInfo with S8Director in room, S10RNInfo confirmed the above chart findings at the time of computer record review.

2) Failing to ensure the RN assessed and reassessed the elimination status:
Patient #2Review of the medical record for Patient #2 revealed a 58 year-old man admitted to the hospital in the intensive care unit on 01/17/16 and discharged on 01/20/16. Diagnoses included aspiration pneumonia, Recurrence of Stage IV B Squamous Cell Carcinoma of Maxillary Antrum, and Constipation.
A review of the patient's History and Physical revealed the physician documented the patient had a problem with constipation and preferred suppositories.
A review of Patient #2's EMR revealed the initial RN assessment performed in the intensive care unit revealed the date of Patient #2's last bowel movement was not documented.
Review of the initial nursing assessment by S13RN, upon arrival to the medical surgical unit on 01/18/16, revealed no documented evidence of an assessment of Patient #2 ' s last bowel movement.
Review of the EMR under the "Gastrointestinal Assessment Section" revealed the following assessment: 01/19/16 at 8:00 a.m. by S13RN: patient is constipated and has hypoactive bowel sounds. Review of the EMR revealed no documented evidence any interventions were implemented for the patient's constipation.
In an interview on 05/04/16 at 11:28 a.m., S13RN reviewed the EMR and confirmed she did not document in the initial assessment the date of the patient's last bowel movement; there was no documented evidence in the EMR she contacted Patient #2's physician regarding the constipation, and there was no documented evidence that any interventions were implemented or provided at that point for the patient's complaint of constipation.
In an interview on 05/04/16 at 12:19 p.m., S4RN indicated that patients' intake and output (to include bowel movements) was assessed every shift, and if patients had bowel movements, it was to be documented on the intake and output section. S4RN further indicated if nothing was documented on the intake and output sections, it indicated there was no bowel movement. S4RN also indicated if a patient has not had a bowel movement in 24 hours, the physician is to be notified; and, if medications and/or interventions are administered, the nurse was to reassess patients for the effectiveness/outcomes of medication and/or interventions administered, and notify the physician if the desired outcome was not achieved.
Review of the MAR revealed a glycerin adult suppository was administered on 01/19/16 at 12:58 a.m. Further review of the EMR revealed there was no documented evidence that the nurse assessed the patient for the results of the glycerin suppository administered to the patient.
Review of the EMR revealed the following documentation by S14RN: 01/19/16 at 8:05 p.m.: the patient is constipated; 01/19/16 at 11:00 p.m.: " Notified (Independent Licensed Practitioner ) that patient complained of constipation and abdominal cramping. Patient has glycerin suppository ordered but not due to be given until 1:00 a.m. Order received Ok to give early. Upon administering could feel hard stool in rectum. Will continue to monitor. " Review of the MAR revealed a glycerin suppository was administered on 01/19/16 at 11:49 p.m. Further review of the EMR revealed there was no documented evidence that the nurse assessed the patient for results of the glycerin suppository administered to the patient. On 01/20/16 at 4:00 a.m.: " Notified (Independent Licensed Practitioner) that patient still complaining of constipation and severe abdominal cramping. Patient did just have small extremely hard bowel movement. Whole glycerin suppository noted. Patient and wife requesting something more. Orders placed for soap suds suppository (enema). Patient resting quietly as this time. Will administer first thing in a.m. " On 01/20/16 at 6:00 a.m.: " Administered soap suds enema with minimal results. Patient still has large amount of hard stool in rectum. "
Review of the EMR revealed no documented evidence S14RN contacted the patient's physician or provided any further intervention to address the patient's constipation and large amount of hard stool in his rectum.
Further review of the "flow sheet" EMR revealed documentation that Patient #2 had bowel movements on the following dates: 01/20/16 at 2:00 p.m., 01/20/16 at 5:40 p.m. and 01/22/16 at 5:26 p.m.
In an interview on 05/03/16 at 3:01 p.m., S12RNInfo reviewed the entire EMR with the surveyor and confirmed the above findings in the EMR.
Patient #4Review of the medical record for Patient #4 revealed he was a 67-year-old male admitted to the hospital on 04/27/16 with a diagnosis of Bilateral Lower Extremity Cellulitis.
Review of the EMR revealed documentation Patient #4 had bowel movements on 04/27/16, 05/02/16, and 05/03/16. Further review of the EMR under the Gastrointestinal Assessment Section, between the dates of 04/27/16 and 05/02/16, revealed all of the assessments were documented as "Within Defined Limits" but no bowel movements were documented.
In an interview on 05/03/16 at 3:25 p.m., S12RNInfo reviewed the EMR with the surveyor and confirmed there was no documented evidence in the EMR that Patient #4 a bowel movement between the dates of 04/27/16 and 05/02/16.
In an interview on 05/04/16 at 2:30 p.m., S11RNInfo reviewed the EMR with the surveyor and confirmed there was no documented evidence in the EMR that nursing had identified and addressed that Patient #4 did not have a bowel movement from 04/27/16 until 05/02/16, and there was no documented evidence that Patient #4's physician had been notified of the issue.


31048

Based on record review and interview, the hospital failed to ensure there was a comprehensive, individualized, nursing care plan developed and updated for all patient care needs for 2 (#2, #4) of 2 records reviewed for care plans in a total sample of 5 records. Findings:

Review of a policy "Assessment and Reassessment (Hospitalized Patients)" with a revision date of 12/13 presented as current, revealed, in part: "...III Policy Statements 1. Upon admission to the unit, a registered nurse will assess each patient to collect data, determine any immediate needs and make appropriate care assignments. 2. The patient's plan of care, treatment, and services will be based on needs identified by the patient's assessment, reassessment, response to interventions and results of diagnostic testing. 3. Patient care needs and responses to interventions must be reflected and updated regularly in the care plan."

Patient #2
A review of the medical record for Patient #2 revealed a 58 year-old man admitted to the hospital on 01/16/16 and discharged on 01/20/16. Diagnoses included aspiration pneumonia, Recurrence of Stage IV B Squamous Cell Carcinoma of Maxillary Antrum, and Constipation. A review of Patient #2's care plan revealed the patient did not have a comprehensive care plan as evidenced by Patient #2 was not care planned for constipation.

In an interview on 05/03/16 at 3:01 p.m., S12RNInfo confirmed after reviewing the EMR with the surveyor, Patient #2 was not care planned for constipation.

Patient #4
Review of the medical record for Patient #4 revealed a 67-year-old male admitted to the hospital on 04/27/16 with a diagnosis of Bilateral Lower Extremity Cellulitis. A review of Patient #4's care plan revealed the patient did not have a comprehensive care plan as evidenced by Patient #4 was not care planned for cellulitis and the wound care ordered.

In an interview on 05/04/16 at 4:30 p.m., S11RNInfo confirmed after reviewing the EMR with the surveyor, Patient #4 was not care planned for cellulitis and the wound care ordered for Patient #4.

Based on record reviews and interviews, the hospital failed to ensure the nursing care was provided by nurses who were evaluated for competency as evidenced by failure to have documented evidence of competency evaluations of performing skills of assessing and staging wounds/decubitus for 3 (S19, S21, S22) of 6 RNs whose personnel files were reviewed for wound assessment and staging competency.
Findings:

Review of the hospital policy titled "Competency Assessment & (and) Skills Validation", presented as a current policy by S8Director, revealed nursing staff competency is assessed as part of of the initial employment/orientation process and through ongoing assessment and educational activities. Competency assessment is accomplished during both Core and Unit Department based orientation. All professional, licensed, and non-licensed personnel will participate in a Competency Assessment Process to validate competency in an identified area of clinical practice before performing those activities in the clinical setting.

Review of the personnel files of S19RN, S21RN, and S22RN revealed no documented evidence of an evaluation of their competency in performing wound/decubitus assessment and staging.

In an interview on 05/03/16 at 2:45 p.m. with S19RN and S4RN present, S19RN indicated she was hired in March 2016. She further indicated she had not been evaluated for competency for assessing and staging wounds/pressure ulcers since she was hired, but she had a competency evaluation when she worked at the hospital as an agency nurse (review of competency evaluation revealed it was a self-assessment with no documented evidence of a competency evaluation by a hospital-employed RN).
In an interview on 05/04/16 at 7:55 a.m. with S21RN and S4RN present, S21RN indicated she initially started in September 2015 as an agency nurse and went full-time as an employee on 03/28/16. S4RN confirmed she didn't have evidence to present of a competency evaluation for assessing and staging wounds that had been conducted by a hospital-employed RN when S21RN worked as an agency nurse.
In an interview on 05/04/16 at 8:55 a.m. with S22RN and S4RN present, S22RN indicated she has worked here about 1 year. During orientation she was taught to assess patients when they arrive to know if the patient has pre-existing wounds and to consult wound care if wounds are identified. She further indicated the preceptor goes over it with her when doing patient care and she has had online training, but she relies on the wound care nurse for assessment more than anything. She further indicated she s "not the best at staging and would document exactly what I see, such as color, drainage." S22RN indicated she wouldn't measure any wounds. S22RN indicated she didn't know the protocol for reassessment, measurement, and staging of wounds.

Based on record reviews and interviews, the hospital failed to ensure the written notice of its decision provided to patients contained the results of the grievance process as evidenced by failure to have the outcome of the investigation of each complaint voiced in the grievance addressed in the letter for 2 (#1, #2) of 2 patient grievances reviewed.
Findings:

Review of the hospital policy titled "Patient Grievance Management", presented as a current policy by S8Director, revealed when an issue/concern cannot be promptly resolved (Grievance), the Patient Relations representative will initiate the grievance process by entering the data into the electronic tracking system and will send out an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process. The Patient Relations Department will immediately forward a copy of the grievance to the appropriate investigators (Hospital manager/Director or Physician) by electronic mail. Upon the investigator's receipt of the grievance, an investigation will begin within 1 business day to address the specific issues/concerns that were communicated by the patient/family. A written resolution letter will be sent to the patient that addresses the substance of each complaint made, and will also contain the results of the grievance process.

Patient #1
Review of Patient #1's mother's grievance received by the Patient Relations department on 02/08/16 revealed the following complaints: her son signed a discharge appeal, and his copy was stolen from his room by a nurse which caused him to be discharged on Saturday and not the following Monday like he requested; she is waiting on the coroner's report and stated her son's cancer diagnosis is incorrect and that he actually died from asbestos poisoning and that it's "a cover up"; while her son was in the hospital the charge nurse stated she wouldn't respond to the call and stated her son's mistreatment was race-related and he was discharged with a bedsore and without oxygen.

Review of documentation presented by S8Director revealed Patient #1 signed with initials on 01/15/16 at 11:10 a.m. a form to appeal his discharge that was sent to Company A on 01/15/16. Review of documentation by the case manager on 01/16/16 at 11:25 a.m. revealed the case manager spoke with a representative of Company A who stated they had reviewed Patient #1's discharge appeal and determined Patient #1 was ready for discharge and had until 12:00 p.m. 01/17/16 to be discharged. Company A's representative reported to the case manager that she (Company A representative) had attempted to call Patient #1's mother, who filed the appeal on her son's behalf, but the first time Patient #1's mother hung up on the representative. When the representative attempted follow-up calls, the phone calls were not answered, and Patient #1's voice mail box was full. Further review of documentation by the case manager revealed at 11:30 a.m., she spoke with Patient #1 at his bedside and advised him that he had lost his discharge appeal. Patient #1 at that time indicated his cousin was here, and he was ready to go home. Arrangements were made to discharge Patient #1 on 01/16/16.

Review of S4RN's response of her investigation to S16PR on 02/24/16 at 11:52 a.m. revealed "in receiving a statement from (name of charge nurse), the call bell was falsely alarming in which she explained that she would place a work order in to remedy the false alarming. The patient's mother in turned might have mistakenly perceived that it was a refusal to respond to the alarm. The patient was not mistreated due to race as we don discriminate, and oxygen is typically not utilized for hospice transportation. I did not see a bedsore listed for this patient while completing a chart review."

Review of the resolution letter sent to Patient #1's mother dated 02/25/16 and signed by S4RN revealed the following:
"This letter is to advise that we have undertaken and completed a review of the concerns you presented. This review included a medical record review, as well as discussions with the staff involved in your son's care. You shared how you felt the nurses on the 9th floor, Medical Surgical Unit (MSU) did not provide a thorough explanation surrounding his discharge. We apologize for any discomfort or concern this incident has caused and thank you for bringing this matter to our attention..." There was no documented evidence that the discharge appeal process and responses from Company A were addressed in the resolution letter. Further review of the resolution letter revealed "You also shared how you felt our employees you encountered on MSU were unhelpful when you were pressing the call light. Please know that the staff involved in your care have been made aware of your concerns and the importance of responding to all patient calls in a timely, compassionate manner has been reinforced..." There was no documented evidence that Patient #1's mother's response letter addressed the information received from the charge nurse about the call light, the questionable diagnosis of Patient #1, and being discharged with a bedsore and without oxygen.

In an interview on 05/04/16 at 9:20 a.m. with S15PR and S16PR present, S16PR indicated Patient #1's mother complained by telephone on 02/08/16. She further indicated the initial resolution letter was not received by Patient #1's mother, because the address had changed. When Patient #1's mother reported on 03/21/16 that she didn't receive the letter, the resolution letter was resent to her. During the interview a request was made by the surveyor of the evidence that the resolution letter was resent. Both S15PR and S16PR confirmed the resolution letter sent to Patient #1's mother did not address all the complaints voiced in the initial grievance report. They indicated they did not have any documentation of the investigation conducted by S4RN.

No further evidence that the resolution was resent to Patient #1's mother was provided as of the time of exit on 05/04/16 at 5:40 p.m.

In an interview on 05/04/16 at 9:45 a.m., S4RN confirmed the resolution letter did not include information about all the complaints voiced by Patient #1's mother in her grievance. She indicated when she documented that Patient #1 didn't have a bedsore, she meant that he it wasn't a hospital-acquired bedsore. When informed that the medical record review revealed Patient #1 did not have a decubitus upon admit, she had no explanation to offer.

Patient #2
Review of Patient #1's mother's grievance, received by the Patient Relations Department on 02/22/16, revealed the deceased patient's wife complained that Patient #2 was severely impacted and in a lot of pain, and Patient #2 used the oral suction device to disimpact himself; the nursing staff did not respond to the call light in a timely manner on the day and night shifts.

Review of the resolution letter sent to the complainant for Patient #2, dated 03/18/16, revealed the following, in part: ..."This letter is to advise that we have undertaken and completed a review of the concerns you presented. This review included a medical record review, as well as discussions with the staff involved in your husband's care. You shared how you felt our employees you encountered on the Medical Surgical Unit were unhelpful when you or your family were pressing the call light. Please know that the staff involved in your husband's care have been made aware of your concerns and the importance of responding to all patient calls in a timely, compassionate manner has been reinforced. Please be assured we are currently in the process of hardwiring purposeful hourly rounding to all of our patients and have used your feedback to support the purpose of this initiative to staff. This new process should not only assist in decreasing the number of call lights in an effort to get in touch with staff, but should also make our patient stay more comfortable one..." The author of the letter was S4RN.

In an interview on 05/04/16 at 1:15 p.m., S16PR indicated they had received the complaint from Patient #2's wife on 02/22/16 via a telep

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having nurse call lights on the hand rails of patient beds on the 9th floor Medical-Surgical Unit not functioning for 25 of 52 beds located on the 9th floor Medical-Surgical Unit. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the call light on the bed hand rail rather than the hand held call light.
Findings:

Observation on 05/02/16 at 11:20 a.m. of rooms on the North and West wings of the 9th floor Medical-Surgical Unit revealed patient beds with the nurse call bell on the side rail not functioning, either due to the wall connection to the bed connection not being attached, the wall connection and bed connection connected but the call system not functioning, or having no wall and/or bed connection present, in Rooms a, b, c, d, e, f, g, h, i, and j.

In an interview on 05/02/16 at 11:40 a.m., the daughter of Patient R3, who was in Room "k," indicated they were told to use the hand held call light, because the call light on the bed hand rail did not work.

In an interview on 05/02/16 at 12:03 p.m., Patient R4, who was in Room "h," indicated she was instructed to use the hand held call light, and if it was not working, to use the call light button on the bed hand rail.

Observation on 05/02/16 at 11:20 a.m. of rooms on the South and East wings of the 9th floor Medical-Surgical Unit revealed patient beds with the nurse call bell on the side rail not functioning, either due to the wall connection to the bed connection not being attached, the wall connection and bed connection connected but the call system not functioning, or having no wall and/or bed connection present, in Rooms l, m, n, o, p, q, r, s, t, u, v, w, x, and y.

In an interview on 05/02/16 at 11:35 a.m., S5RN indicated patients communicate their need for assistance by use of an electronic call light system. She indicated the bed rails have a call button for use, and each patient has a hand-held call button for use. She also indicated they "encourage the patients to use the hand-held call light."



31048

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 the RN assessed and staged and reassessed patients' wounds/decubitus and performed wound care in accordance with hospital policy and physician orders for 3 (#1, #4, #5) of 4 patient records reviewed with wounds from a total sample of 5 patients. 2) Failing to ensure the RN assessed and reassessed the elimination status of 2 (#2, #4) of 5 patient records reviewed with elimination problems from a total sample of 5 patients. Findings:
Review of the hospital policy titled "Assessment and Reassessment (Hospitalized Patients)", presented as a current policy by S8Director, revealed that upon admission to the unit, a RN will assess each patient to collect data, determine any immediate needs, and make appropriate care assignments. The patient is reassessed as necessary based on his/her plan of care for changes in his/her condition. Patients will be assessed when a significant change in the patient ' s condition occurs and in response to intervention. Essential elements of the reassessment include focused physical system review based on the medical diagnosis.
1) Failing to ensure the RN assessed and staged and reassessed patients' wounds/decubitus and performed wound care in accordance with hospital policy and physician orders: Review of the hospital policy titled "Nursing Clinical Practice Guidelines", presented as a current policy by S8Director, revealed the hospital will use primarily four types of clinical nursing standards that include the following: 1) Clinical procedures in the approved Mosby's Skills procedures and hospital-developed procedures; 2) Clinical Practice Guidelines Approved Elsevier Clinical Practice Model guidelines; 3) Basic Care Guidelines; and 4) Clinical Interventions Guidelines of hospital-developed guidelines.
Review of the hospital policy titled "Patient Care Consults", presented as a current policy by S8Director, revealed a consult can be generated for select disciplines based on pre-established high risk criteria upon admission or periodically throughout the hospital stay. A notation is made in the computer and/or progress notes regarding assessment findings, recommendations, and follow-up needed. There was no documented evidence that the timeframe for completing the evaluation by the consultant was addressed and whether reassessment by the wound care nurse had to be done after the initial assessment.
Review of "Pressure Ulcer Prevention and Treatment", presented by S8Director as the resource from Elsevier Clinical Practice Model guidelines used by the nursing staff for assessing, reassessing, and documenting pressure wounds and staging, revealed that a suspected DTI was defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further review revealed a through nursing assessment should be completed upon admit that includes all skin surfaces. The skin should be assessed at least daily and more often if abnormalities are identified, noting skin alteration changes. When an ulcer is identified, the stage of the ulcer should be determined with an assessment of the location, size on initial assessment and at least weekly, and on discharge (use centimeters to document length, width, and depth). The condition of the dressing should be assessed at least once a shift. At the time of dressing change, the character of and amount of drainage should be assessed and the presence or absence of odor.
Review of "Skin Integrity Impairment, Risk / Actual", presented by S8Director presented by S8Director as the resource from Elsevier Clinical Practice Model guidelines used by the nursing staff for assessing, reassessing, and documenting arterial, venous, and diabetic ulcers, revealed that wound care management included the following: measure length, width, and depth of the affected area in centimeters weekly; note exudates or changes in wound characteristics, such as erythema, induration, maceration, odor, pain, correlating with dressing type and frequency; protect wounds from sources of shear and friction; avoid pressure on wound; outline specific skin care treatment on the plan of care including doctor ' s orders.
Patient #1 Review of Patient #1's medical record revealed he was admitted on 01/09/16 and discharged on 01/16/16. Review of his emergency department's nurse's note revealed his skin upon arrival was warm, with normal skin turgor, dry oral mucus membranes, and he had no rashes or lesions.
Review of Patient #1's "Discharge Summary" documented by S20MD on 01/16/16 at 1:27 p.m. revealed Patient #1 had a Stage II pressure ulcer, 7 cm in width with no depth noted, and black, discolored tissue beginning to shear and leaving a moist dark-red wound bed, partial thickness, and no drainage or odor noted.
Review of the nursing assessment documented during the hand-off from the emergency department to the inpatient nursing unit revealed Patient #1's skin was warm and dry with no documented evidence of wounds/pressure ulcer.
Review of Patient #1's medical record revealed the following assessments of his pressure ulcer identified on 01/11/16 at 10:00 a.m.: 01/11/16 at 10:00 a.m. by S22RN - Stage III, dressing dry, intact; small amount yellow/tan drainage; cleaned with soap and water; dressing changed, foam. There was no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/12/16 at 12:41 p.m. by S21RN - Stage III, small amount of yellow, tan drainage. There was no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/12/16 at 11:49 p.m. by S21RN - no documented evidence of measurements, appearance of surrounding skin and wound bed, and presence or absence of tunneling. 01/13/16 at 8:09 a.m. by S18RN - Stage III with small amount yellow, tan drainage; cleaned with soap and water, barrier applied, Telfa island dressing applied. 01/13/16 at 8:30 p.m. by S21RN - Stage III scant blood-tinged drainage, reddened appearance, wound edges intact; 01/14/16 at 8:00 p.m. by S23RN - Stage III no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact; 01/16/16 at 8:22 a.m. by S19RN - Stage III, no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact, jagged; 01/16/16 at 12:07 p.m. by S19RN - Stage III, no drainage, no odor, reddened appearance, periwound area normal skin tone, wound edges intact, jagged. Braden Risk Assessments documented varied between 11 - 16.
In an interview on 05/03/16 at 1:30 p.m., S8Director indicated S23RN was no long