HospitalInspections.org

Based on a review of policies and procedures, complaint/grievance reports, incident/event reports, and staff interviews, the hospital failed to ensure a written notice of its decision containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Five of six grievances reviewed (Grievances #5, 6, 8, 9, and 10 of Grievances # 5, 6, 7, 8, 9 and 10) did not contain a written response to the complainant containing the required elements.

Findings:

1. Four grievances (Grievances #5, 6, 8, and 9) were marked resolved on the grievance log, but there was no written response to the complainant. Hospital Staff J stated on 08/26/10 in the afternoon that the hospital felt like these grievances/complaints were resolved in a timely manner before the patient/complainant had been dismissed from the hospital. Staff J also stated that since they had been resolved during the patient's hospital stay they did not require a written response even though they did not meet the requirement that the complaint is resolved at the time of the complaint by staff present. These complaints required an investigation and were not resolved at the time of the complaint by staff present.

2. Grievance #5 did not contain evidence the second complaint voiced by the complainant had been addressed/investigated. This finding was reviewed and verified with Staff J.

3. Grievance #10 was found in the event/incident report. Under the "Type of Event" was documented "Complaint/Grievance filed internally." Review of the documentation supplied from Staff J did not demonstrate the hospital had investigated and sent a written response with the required information to the complainant. Staff verified a written response was not sent to the patient.

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 two of two (Patient #2,#3) patient records reviewed of patients with identified skin problems, the nurse did not follow the hospital's policy to identify and provide preventive care and the supervising nursing staff did not supervise to ensure policies were followed and nursing assessments were checked for accuracy and completeness of documentation.

Findings:

The hospital's policy for skin assessment, entitled Skin and Wound Care Team, stipulated that for patients whose Braden Scale assessment was 10-12 or very high risk (<9) the wound care team will meet weekly as part of the interdisciplinary team (IDT) to evaluate current treatment and healing progress of wound care patients. This policy also stipulates nursing will "assess skin on every patient each shift, identify skin breakdown, initiate preventive measures based on Braden scores to maintain skin integrity, document existing and potential problems.

1. Patient #3's (the patient mentioned in the complaint) Braden Scale on admission, 05/12/2010, was 12. There was no documentation in the chart to support the wound care team had been notified about the Braden scale assessed at the time of admission as a "12". On 5/26/2010, Staff B made a late entry for 5/24/2010 and documented breakdown on the patient's toe. Documentation during the entire stay varied from a Braden of 7 to a high of 16. Of the fifty nursing assessments documented in Patient #3's chart, twenty five of the nursing assessments indicated "skin was intact". Of the other twenty five entries where "skin not intact" was documented, 25 of 25 entries did not have documentation about where the skin was not intact or if there were wounds.

On 6/7/2010 a late entry for 6/4/10 was entered by Staff B. This entry indicated Patient #3 had four wounds on the day of discharge:
a. Right great trochanter Stage II, hospital acquired
b. Right heel Stage DTI (deep tissue injury), hospital acquired
c. Right dorsal foot, Stage II, hospital acquired
d. Left fifth toe Stage II, hospital acquired

The documentation on the interdisciplinary care plan notes dated 5/20, 5/27, 6/3 all stipulated "no actively managed wounds". None of the physician progress notes indicated there was skin breakdown. Staff did not follow the hospital's policy to provide skin and wound management for Patient #3.

On 08/26/2010 in the afternoon surveyors interviewed Staff A , surveyors asked when wound care management was supposed to get involved with patients. Staff A stated nursing is to notify the wound care nurse if the Braden scale is less than 14. Staff A also indicated there were discrepancies in wound/skin documentation. Staff A stated the wound management nursing personnel were inservicing all staff beginning this week. Staff A stated all new personnel will go through the program at orientation.


2. Patient #2 - admitted on 05/13/2010. The initial nursing assessment performed on 05/13/2010 at 2232 listed the surgical wound as the only skin problem but did not describe the wound. The next nursing assessment, at 0315 on 05/14/2010 noted the patient also had a dressing to the lower left side of the back. On 05/14/2010 at 1100, the wound care nurse noted a wound on the right side in addition to the surgical wound and the wound on the left lateral mid-back. The wound care nurse described all three areas of skin disruptions. The patient developed an excoriation from the tape used. The nurse on 05/29/2010 described the site and the intervention she utilized. Throughout the patient's stay, until discharge on 06/29/2010, nursing notes did not contain complete descriptions of the patient's skin or interventions provided, including reminding the patient to change positions frequently to alleviate pressure. The supervising nurse did not supervise to ensure nursing staff assessed the patient's condition , provided appropriate interventions on behalf of the patient, and accurately documented these assessments.

The documentation on the interdisciplinary care plan notes dated 05/20, 05/27, 06/03, and 06/10/2010 all stipulated "no actively managed wounds". None of the physician progress notes indicated there were skin problems other than the surgical site. Staff did not follow the hospital's policy to provide skin and wound management for Patient #2.

These findings were reviewed with Staff A, I and J on the afternoon of 08/26/2010.