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Based on record review and interviews, the facility failed to provide the patient with written notice of its decision, the steps taken to investigate the grievance, and the results of the grievance process, in 2 of 3 patient/families with grievances (patient #1 and patient #12). This deficiency could potentially affect all patients on 7 East, (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).

Findings include:

Review of Complaint and Grievance Procedure Policy #519841 reviewed 12/12/16 at 2:16 PM. Under Procedure 2 B "The Nursing Director or designee will inform the patient of the specific time frame for review and response during initial contact with the patient. Most reviews should be completed with a written response to the patient within 7 (seven) days. If more time will be needed, the patient shall be informed of the progress of the investigation, and given a reasonable timeframe for completion." 2 G "The final report including resolution and a copy of written communication to the patient should be forwarded and/or entered in the Event Reporting System/Professional Relations System (ERS/PRS)."

Reviewed complaint ticket #TAX1963597 on patient #12 on 12/15/16 at 11:00 AM with Manager of Patient/Family Complaints and Grievances Q. Ticket #TAX1963597 issued 10/20/16 at 12:45 PM, received by Med Surg 7E for follow-up 10/20/16 at 1:15 PM, action taken 10/20/16 at 1:15 PM "informed patient that a call light report would be pulled so that I could determine specific times and speak to the appropriate individuals...". Issue investigation, due date 10/27/16, under Immediate Action Taken states "Spoke with involved staff... Call light report to be pulled... Nurse assignment readjusted." Feedback ticket assigned to Manager Patient Services 7 East O, due date 10/31/16. Investigation summary dated 10/24/16 at 1:35 PM "Examined call light report. Reinforced with staff the importance of answering the call light in a timely manner." Manager Q stated there is no follow-up letter, "there should have been".

Reviewed complaint ticket #WKY1916570 on patient #1 on 12/15/16 at 10:00 AM with Manager of Patient/Family Complaints and Grievances Q. Ticket #WKY1916570 issued 7/17/16 at 6:30 PM, received by Med Surg 7E on 7/19/16 at 3:00 PM. Noted under Complainant's resolution expectation "Patient's family, [complainant A], would like to be contacted by each of the involved departments ... with the specific findings ...". Investigation Summary assigned to Manager O with Due Date 8/15/16. Follow-up letter was sent to complainant A on 8/18/16. During interview with Manager Q, it was asked why there was a due date of 8/15/16 on Ticket WKY1916570 and why the follow-up letter was not sent within 7 days as expected by their Grievance Policy 519841. Manager Q could not explain, stating their hospital system is in the process of merging their grievance process and everyone is doing it a little different now.

Reviewed complaint ticket #AAW1912788 from complainant A on behalf of patient #1, on 12/15/16 at 10:00 AM with Manager of Patient/Family Complaints and Grievances Q. Ticket #AAW1912788 issued 7/16/16 , received by Med Surg 7E on 7/19/16 at 3:30 PM. Complainant's resolution expectation "[Complainant A] would like the department leader to follow-up with her in regards to an additional information." Interviewed Manager Q, Manager Q stated there is no follow-up letter, "there should have been".

Reviewed complaint ticket #TCB1913692 from complainant A on behalf of patient #1, on 12/15/16 at 10:00 AM with Manager of Patient/Family Complaints and Grievances Q. Ticket #TCB1913692 issued 7/17/16 , received by Med Surg 7E on 7/19/16 at 3:00 PM. Complainant's resolution expectation "[Complainant A] would like to be contacted with follow-up information from family practice." Interviewed Manager Q, Manager Q stated there is no follow-up letter, "there should have been".

Reviewed complaint ticket #DFD1913951 from complainant A on behalf of patient #1, on 12/15/16 at 10:00 AM with Manager of Patient/Family Complaints and Grievances Q. Ticket #DFD1913951 issued 7/19/16 , received by Med Surg 7E on 7/20/16 at 8:00 AM. Complainant's resolution expectation "[Complainant A] would like to be contacted by the head of the department for family practice." E-mail addressed to Patient Representative U on 8/15/16 indicated "I did try to reach [complainant A] on three separate occasions. I did leave a voicemail message with my contact information to call me back to discuss further."Interviewed Manager Q, Manager Q stated there should have been a follow-up letter sent.

Based on staff interviews, and record review, the nursing staff failed to follow the hospital policies and procedures for post-surgical assessments in 5 of 10 post-surgical patients (patients # 1, 2, 4, 5 and 7), the hospital failed to have nursing policies and procedures for care planning and failed to ensure that the nursing staff developed, communicated, and kept current nursing care plans for each patient in 9 of 10 patients (patients #1, 2, 3, 4, 6, 7, 8, 9, and 10), and failed to follow hospital policies and procedures while administering blood transfusions and IV opioids in 4 of 10 patients (patients #1, 2, 3, and 10). These deficiencies have the potential to affect all post-surgical patients on 7 East (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).


Findings include:

The hospital failed to monitor the clinical activities of their staff after surgical procedures. (see A395)

The hospital failed to ensure that the nursing staff develops, communicates, and keeps current, a nursing care plan for each patient. (see A396)

The nursing staff failed to safely administer blood products and IV opioids. (see A409)

The cumulative affects of the systemic problems prevent the nursing service from functioning in a safe and effective manner.

Based on interview and record review the nursing staff failed to follow the hospital policies and procedures for post-surgical assessments in 4 of 10 post-surgical patients (patients #1, 4, 5, and 7). These deficiencies had the potential to affect all surgical patients on 7 East, (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).

Findings include:

The facility policy titled Vital Signs - Post-Operative-Post-Procedure, Policy #1512966, dated 2/2006, Expiration 4/2018 was reviewed on 12/12/16 at 2:00 PM. This document states under Policy, 2. "minimum standard routine for post-operative/post-procedure vital signs will include the following: A. Vital signs (blood pressure [BP], pulse [P], respirations [R], pulse oximetry [PO]) and assessment pertinent to the surgical procedures...1. Every 15 minutes x 3. 2. Every 30 minutes x 2. 3. Every hour x 1. 4. Every 4 hours x 24 hours 5. Then prn for patient condition. B. Temperature is taken at least once upon arrival and prn..."

Patient #1's medical record was reviewed on 12/13/16 at 9:50 AM with CNL K. Staff failed to include complete post-operative vital signs per policy #1512966. Patient #1 arrived on 7 East on 7/17/2016 at 4:00 PM. Post-surgical vital signs were blood pressure (BP) 106/53, heart rate (HR) 82, respiratory rate (RR) 20, pulse oximetry (PO) 90% on 2 liters of oxygen per minute (l/m) by nasal cannula (NC). At 9:00 PM BP was 84/46. A full set of vital signs were not documented from 7/17/16 at 6:30 PM until Rapid Response code was called on 7/18/16 at 1:00 AM.

Patient #4's medical record was reviewed on 12/13/16 at 11:50 AM with CNL K. Patient #4 was transferred from the Post Anesthesia Care Unit (PACU) to 7 East after open reduction internal fixation (ORIF) right femur on 7/25/16 at 9:40 PM. Post-surgical vital signs every hour x 1 was missing on 7/26/16 at 12:20 AM per facility policy # 2297483.

Patient #5's medical record was reviewed on 12/13/16 at 12:30 PM with CNL K. Staff failed to monitor patient #5 post-operatively per facility policy #1512966. Patient #5 left PACU on 8/6/12 at 1:04 PM. No one hour post-surgical vital sign taken. Vital signs at 8:01 PM missing pulse oximeter reading.

Patient #7's medical record was reviewed on 12/13/16 at 1:32 PM with CNL K. Staff failed to monitor patient post-operatively per facility policy #1512966. Patient was transferred from PACU to 7 East after a ORIF right tibia on 9/27/16 at 5:20 PM. Post-surgical temperature was not taken on arrival to the floor per facility policy # 2297483.


After reviewing patients #1, 4, 5 and 7's post-surgical assessments with Clinical Nurse Leader (CNL) K, K stated in an interview on 12/1316 at 2:10 PM, that patients #1, 4, 5 and 7's post-surgical assessments were incomplete.

Based on record review and interview, the hospital failed to have nursing policies and procedures for care planning and failed to ensure that the nursing staff developed, communicated, and kept current nursing care plans for each patient. The facility failed to individualize patient plans of care in 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, 10) and failed to review patient plans of care and update them in response to the assessments in 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, 10). This deficiency could potentially affect all patients on 7 East, (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).


Findings include:

Reviewed facility's policy titled Assessment-Reassessment - Patient, Policy #832894 dated 4/1993, Expiration 5/2017 on 12/12/16 at 2:16 PM. This document stated under Nursing 3. Determining Patient Needs/Diagnosis/Care Planning "3. Information gathered from multi-disciplinary Care Coordination Rounds is documented on the plan of care."

During interview on 12/15/16 at 11:30 AM, Director of Medical Services F, stated that their paper care plan process was changed to an electronic process and that the facility does not have a policy on care planning.

During interview on 12/15/16 at 9:56 AM, Clinical Nurse Leader K confirmed that the paper care plans were not individualized or updated.

Review of patient #1's medical record on 12/15/16 at 8:30 AM revealed patient #1 was admitted through the Emergency Department 7/15/16 at 11:18 PM with a comminuted fracture right proximal humerus. Care plan was initiated 7/16/16 consisting of five problems. The outcome met column had 7/20/16 written in. Altered Comfort-acute pain, medication management, anxiety reduction, Coping Enhancement, Safety-risk for injury/fall-educate regarding safety, Impaired Mobility-Safety-education were checked. Nothing is checked under Knowledge deficit. On 7/18/16 a Rapid Response was called on patient #1. There was no indication of a change noted in the care plan. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #1.

Review of patient #2's medical record on 12/15/16 at 8:35 AM revealed patient #2 was admitted 6/25/16 at 4:24 AM with a right hip fracture. Care plan was initiated 6/25/16 consisting of six problems and outcome met column had 7/5/16 written in. Problems checked were Altered Comfort-acute pain-medication management, environment management, Safety-risk for injury/fall-initiate fall/risk protocol, implement bed alarm, educate regarding safety, Knowledge Deficit-procedure/treatment regimen, activity/exercise, medication, VTE [venous thrombis embolism, i.e. blood clot] prevention checked, Impaired Mobility-Hip fx (fracture), bedrest written in, Impaired Skin Integrity. On 6/26/16 a Rapid Response was called on patient #2. There was no indication of a change noted in the care plan. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #2.

Review of patient #3's medical record on 12/15/16 at 8:40 AM revealed patient #3 was admitted through the Emergency Department 07/18/16 at 12:07 AM with a chief complaint of right hip, shoulder pain. 7/21/16 care plan was initiated with five problems checked and 7/25/16 written in the outcome met column. Problems checked included Altered comfort-acute pain-medication management, anxiety reduction, Safety-risk for injury/fall-initiate fall/risk protocol, Knowledge Deficit-infection control, incision site, incision site care, infection control, Impaired Mobility-safety, exercise therapy, Impaired Skin Integrity-written in was excessive dry skin, surgical incision and small open area, blister. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #3.

Review of patient #4's medical record on 12/15/16 at 8:45 AM revealed patient #4 was admitted 07/24/16 at 8:58 PM with a right femoral hip fracture. 7/24/16 care plan was initiated with six problems checked and 7/28/16 written in the outcome met column. Problems checked included Altered comfort-acute pain-medication management, anxiety reduction, distraction relaxation therapy, Coping Enhancement, Safety-risk for injury/fall-educate regarding safety, Knowledge Deficit-procedure/treatment regimen, pre-operative/post-operative, VTE prevention, Impaired Mobility-safety, education, Impaired Skin Integrity-skin intact, skin compromised-written in was abrasion/bruising. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #4.

Review of patient #6's medical record on 12/15/16 at 8:50 AM revealed patient #6 was under observation 12/06/2016, admitted to 7 East on 12/07/2016 at 2:20 PM, diagnosis Pelvic Abscess. Care plan was initiated 12/06/2016, Altered comfort-acute pain, chronic pain, Medication management, anxiety reduction, environment management, distraction relaxation therapy checked. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #6.

Review of patient #7's medical record on 12/15/16 at 8:55 AM revealed patient #7 was admitted through the Emergency Department on 9/08/16 after a bike fall. Care plan was initiated 9/08/16 with two problems checked and 10/01/16 written in the outcome met column. Problems checked included Knowledge Deficit-procedure/treatment, activity/exercise, medication, teaching: procedure/treatment, teaching: prescribed activity/exercise, teaching prescribed medication, other {understanding of chest trauma} written in, Impaired mobility-safety-mobility Level-chair checked. On 9/15/16 form 140799 Patient Plan of Care was initiated and written under Care Round Update was 1. [increase] activity. 2. Pain control with PCA [patient-controlled analgesia]. 3. D/c (discontinue) Foley? 4. NPO (nothing by mouth) - PO (by mouth) meds? Patient #7 had a perforated duodental ulcer on 9/14/16 and an Open Reduction Internal Fixation [ORIF] of his right tibia on 9/27/16. The care plan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #7.

Review of patient #8's medical record on 12/15/16 at 9:00 AM revealed patient #8 was admitted for observation on 10/24/16, diagnosed with a left distal femur fracture and admitted on 10/25/16. Care plan was initiated on 10/24/16, five problems were checked, under "Outcome Met" two entries were crossed out and error was written. Problems checked included Altered Comfort-acute pain, medication management, Safety-risk for injury/fall, Knowledge Deficit-VTE prevention, Impaired Mobility-Safety-written in under Outcome met [increase] with 1 walker gait v. slow 10/27/16, Impaired Skin Integrity-skin compromised-written in (bruise to left breast, FX with both ankles circled). The careplan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #8.

Review of patient #9's medical record on 12/15/16 at 9:05 AM revealed patient #9 was admitted 11/10/16 with a hip fracture. Care plan was initiated on 11/10/16, five problems were checked, 11/14/16 was written in Outcome met column. Problems checked included Altered Comfort-medication management, anxiety reduction, environment management, distraction relaxation therapy, Safety-risk for injury/fall,initiate fall/risk protocol, implement bed alarm, educate regarding safety, Knowledge Deficit-wound care, incision site, pre-operative/post-operative,VTE prevention, Impaired Mobility-safety, Impaired Skin Integrity-skin intact. The careplan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #9.

Review of patient #10's medical record on 12/15/16 at 9:10 AM revealed patient #10 was admitted for a planned total left knee replacement on 11/15/2016. Care plan was initiated on 11/15/16, six problems were checked. Problems checked included Altered Comfort-acute pain, chronic pain, Coping Enhancement, Safety-risk for injury/fall, initiate fall/risk protocol, implement bed alarm, educate regarding safety, bleeding precautions, Knowledge Deficit-procedure/Treatment regimen, activity/exercise, medication, infection control, incision site, pre-operative/postoperative,VTE prevention, Impaired Mobility-safety-education exercise therapy, documentation, Impaired Skin Integrity-skin intact, written in (skin looks good!) The careplan did not indicate reason for the diagnoses or indicate any goals and the interventions were not individualized or updated to meet the needs of patient #10.

Based on interview and record review, the nursing staff failed to follow hospital policies and procedures while administering blood transfusions and intravenous (IV) opioids in 4 of 10 patients (patients #1, 2, 3, and 10).These deficiencies had the potential to affect all patients receiving IV opioids or blood transfusions on 7 East (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).


Findings include:

Review of the facility policy titled Assessment-Reassessment - Patient, Policy #832894 dated 4/1993, Expiration: 5/2017 done on 12/12/16 at 2:16 PM. This document states under Nursing, 4. Reassessment, "1. The RN [Registered Nurse] may delegate collection of assessment/reassessment data to other nursing team members as described in unit policies. It is the accountability of the responsible RN to validate the data collected by other nursing team members. Reassessments occur when the patient condition warrants."

Review of the facility policy titled Blood-Blood Product Administration, Policy #2297483, dated 4/2002, Expiration 6/2019 was done on 12/13/16 at 11:30 AM. This policy stated under Procedure, #23, H. "The RN should remain with the patient for the first 15 minutes of the transfusion. 1. Vitals signs should be taken and recorded minimally at 5 minutes, 15 minutes, and at the end of each unit." 3. "Assess patient at least every 30 minutes during transfusion and again at completion of transfusion. Assessment should include observation for signs of a transfusion reaction and the rate of infusion."

Patient #1's medical record was reviewed on 12/13/16 at 9:50 AM. Patient #1's intravenous (IV) site was assessed 7/16/16 at l:15 AM as being dry, intact. Allegation of complainant A attached to intake #WI00029306 stated "at 4:30 PM my Mom and Dad complain about my Mom's left hand being swollen from the IV". The IV site was not assessed again until 7/17/16 at 9:18 PM at which time the IV had infiltrated (fluid leak into the surrounding tissue caused by dislodgment of the catheter). Staff failed to safely assess IV site.

Patient #2's medical record was reviewed on 12/12/16 at 1:35 PM with CNL K. Blood transfusion on 6/27/16 started at 11:24 AM. The first two sets of vital signs were missed per facility policy #2297483. Transfusion end time not documented on patient flow sheet. Staff failed to assess for blood transfusion reaction and document in the medical record per policy #2297483.

Patient #3 was started on 7/21/16 at 10:13 AM with CNL K. Vital signs were taken at the start of transfusion at 10:23 AM and at end of transfusion at 11:54 AM. Vital signs were not documented every 5 minutes for the first 15 minutes. Staff failed to assess patient #3 for signs of transfusion reaction according to facilities Policy #2297483.

Patient #10's medical record was reviewed on 12/13/16 at 2:55 PM with CNL K. Patient #10 transferred from Post Anesthesia Care Unit to 7 East on 11/15/16 at 5 PM and received Morphine 2 mg IV 11/15/16 at 7:34 PM (vital signs at 7:47 PM BP 174/97, HR 98, RR 16, T 96, PO 95% ). Patient #10 received Morphine 2 mg IV 11/15/16 at 10:11 PM. No vital signs or assessment done until 11/16/16 at 1:05 AM. Staff failed to assess IV opioid administration safely.

An interview was conducted with CNL K on 12/13/16 at 1:10 PM, CNL K stated there should be a reassessment 30 minutes after any IV opioid administration. On 12/13/16 at 2:55 PM, CNL K confirmed that assessments were not completed per policy during blood transfusion and IV opioid administration.

Based on record review and interview, the facility failed to ensure consents are legible, signed, dated and timed in 6 of 10 procedures performed (patients #1, 2, 3, and 7). This deficiency has the potential to affect all patients undergoing procedures on 7 East, (inpatient census on 12/12/16 was 14 on 7 East A wing, 11 on 7 East B wing).



Findings include:

Review of the facility policy titled Patient Care-Consent for Treatment-Procedures #931417 dated 9/1986, Expiration 6/2017 was reviewed on 12/13/16 at 10:50 AM. This document states under procedure D. "obtaining a patient's written consent should be executed at the time the physician explains the procedure to the patient. No requirements for what is documented on the consent form are listed in this policy.

The facility policy titled Blood-Blood Product Administration #2297483 dated 4/2002, Expiration: 6/2019 was reviewed on 12/13/16 at 11:30AM. This document states under policy 1 A. form 140503 "is in use at all CSM [Columbia St. Mary's] facilities. The form is used as documented evidence of the patient's treatment of choice...". No requirements for what is documented on the consent form are listed in this policy.

The facility policy titled Documentation-General Rules for Charting #2800342 dated 9/2000, Expiration 8/2019 under Policy 1. E. All entries must be timed (military time) and dated.

An interview was conducted with Director of Accreditation B on 12/15/2016 at 12:12 PM. Director B stated it is expected that surgical consents are to be filled out completely to include the name of the procedure, signature of physician performing the procedure with date and time, signature of the patient or the patient's legal representative and the time and date they signed.

Patient #1's medical record was reviewed on 12/12/16 at 9:50 AM with CNL M and 12/15/2016 at 8:30 AM with CNL K. Patient #1 received 2 units of packed red blood cells (PRBC) on 7/18/16, unit 1 started at 3:57 AM, unit 2 started at 6:12 AM. Form 140503 is on the chart with a sticker in the right upper corner with patient #1's name and Admission Date 7/15/16 on it. Patient signature, witness signature, 7/18/16 at 2:24 AM noted. There is no physician name or procedure documented. There is no physician signature, date or time on this consent.

Patient #1 had a reverse total shoulder arthroplasty right humerus on 7/17/16. The name of the practitioner performing the procedure is not written on the consent.

Patient #2's medical record was reviewed on 12/12/16 at 1:35 PM and 12/15/16 at 8:35 AM. Patient #2 received 3 units of PRBC. Unit 1 was started on 6/27/16 at 11:24 AM, Unit 2 6/29/16 at 1:32 PM, and unit 3 6/29/16 at 7:01 PM. There was no physician name written on the blood consent and the patient signature and witness signature was not dated or timed.

Patient # 3's medical record was reviewed on 12/12/16 at 3:12 PM and 12/15/16 at 8:40 AM. Patient #3 received 3 units of PRBC, unit 1 7/17/16 at 10:55 AM, unit 2 7/18/16 at 10:03 AM and unit 3 7/20/16 at 10:09 AM. There was no physician name written on the blood consent, and the patient signature and witness was not dated or timed.

Patient #3 had an internal fixation right hip on 7/20/16. The name of the practitioner performing the procedure is not written on the consent.

Patient #7's medical record was reviewed on 12/13/16 at 2:10 PM and 12/15/16 at 8:55 AM. Patient had a left leg splint application under moderate sedation on 10/24/16. There is no physician signature, time or date of signature on this consent.