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Based on policy and procedure review, medical record review, grievance file review, and staff interview, hospital staff failed to respond to a grievance according to policy for 2 of 2 grievance files reviewed (Patients #5, #9).

Findings included:

Review of the Complaint and Grievance Resolution policy, number 91RI.RI.0048, dated 02/16/2017, revealed "...When a complaint has been identified as a grievance ....provide a written response to the complainant within seven days acknowledging receipt of the complaint and possible resolution ....If the issue is not resolved and disposition provided within seven days ....provide the complainant a second written correspondence at the time of resolution, which shall be no longer than 30 days ....after receipt of the complaint/grievance. ..."

1. Medical record review of Patient #9, on 11/29/2017, revealed the patient was admitted 09/28/2017 for rehabilitation after a Lumbar Laminectomy (back surgery) on 09/25/2017. Record review revealed admission diagnoses included gait dysfunction, post lumbar laminectomy surgery, atrial fibrillation (rapid, irregular heart rate), anemia, thrombocytopenia (low platelet count that can cause problems with blood clotting) and dementia. Further review revealed Patient #9 was discharged home 10/20/2017.

Review of a Grievance File on 11/30/2017 for Patient #9 revealed an initial grievance response letter dated 10/23/2017, which stated the hospital would communicate the findings once the investigation was completed and it could take up to 30 days for completion. Grievance file review showed a second letter dated 11/28/2017 (36 days later) which stated the concerns had been reviewed and the investigation was complete. It further stated the facility wanted to be thorough in its' response to make sure each concern was addressed and the final response would be forthcoming, but not within the 30 day timeframe. File review revealed policy was not followed.

Interview, conducted 11/30/2017 around 1830, with Administrative Staff #2 confirmed the second letter was not sent within the 30 day time frame and the final response had not been sent.


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2. Closed medical record review revealed Patient #5 was admitted to the named facility after discharge from Acute Care Hospital on 11/18/2016 for left-sided weakness and aphasia (inability to speak clearly or at all) at her assisted living facility. The patient was given IV TPA (a medication to thin or dissolve the blood clot that caused the stroke). Prior to admission to the Rehabilitation facility the patient was also treated with a three day treatment course of Cipro (an antibiotic) for her urinary tract infection at the Acute Care Hospital. Review of the History and Physical revealed" provide patient with close medical monitoring, hospital level of care, three hours of therapy five days a week."

Review of the Grievance File on 11/30/2017 revealed the following response from facility staff #3 to the family grievance. A meeting between patient's family and this facility occurred on 03/08/2017 to discuss concerns of; poor communication between the facility and family, inconsistent rehabilitation plan, patient was alone in a room that was dark, faced a brick wall, and was off of the main corridor, patient was in the bed much of the time, communication was initiated without respect for HIPPA regulations, and patient was transferred to another facility with belongings in disarray. The facility agreed to investigate their records and would provide the family with feedback within approximately thirty days. The family received a letter dated 04/27/2017 from the facility with apologies and had some agreement with family concerns. The letter from the facility referenced education, staff discipline and identified areas for improvement. The reply to the family's concerns occurred some 35 business days after the meeting on 03/08/2017 which surpassed the timeframe of 30 days as stated in the policy.

During an interview on 11/29/2017 at 1155 with Staff #3, Administrative Staff #1, and Administrative Staff #2, Staff #3 indicated that she initiated the grievance process. During the interview, Staff #3 indicated "the delay in responding in writing to the grievance was due to the need to have Risk Management give departmental input for communications to ensure HIPPA (Health Insurance Portability and Accountability Act) regulations were not violated." Interview revealed the response letter contained detailed patient specific information and Staff #3 did not feel comfortable responding without Risk Management oversight and input. Interview confirmed the second letter was not sent within the 30 day time frame.

Based on policy and procedure review, medical record review and staff interviews, hospital staff failed to follow policy for completion of a "Nursing Care Summary", to reassess 3 of 10 patient's (#3; #6; and #7) with a change in vital signs and failed to consistently assess and document skin and pressure areas for 1 of 1 pressure ulcer patients reviewed (Patient #9).

Findings included:

1. Review on 11/27/2017 of the policy titled, "Rehab Hospital Nursing Shift Assessment - Flowsheet", revised 07/24/2014, "....STANDARDS: Nursing Assessment ... 4. Any new abnormal findings or any recognized deviation from the patient's normal pattern for that system will be: *described in the Nursing Care Summary or patient assessment by the RN/LPN *addressed during the review of the care plan and/or as team reports are done....Nursing Care Summary 1. A summary is done by an RN, LPN, or CNA, and reflects the status of the patient with regard to any abnormal findings or any recognized deviation from the patient's normal pattern. ..."

a. Medical record review on 11/28/2017 revealed Patient #3, a 68 year-old male was admitted to the hospital on 11/18/2016 following a stroke on 11/09/2016. Review of the H&P revealed following work up, treatment, and stabilization, the patient was transferred to the named facility for inpatient rehabilitation. Continued review revealed diagnoses included, but not limited to, hemiplegia; difficulty speaking and swallowing; dementia; coronary artery disease (CAD); respiratory failure; hypertension; carotid stenosis. Review of the vital signs flowsheet revealed the systolic blood pressure (SBP) ranged between 142-115, diastolic blood pressure (DBP) 78-70, and O2 saturation 96-93 percent on room air, consistently 11/24/2016-12/06/2016. Review revealed on 11/26/2016 at 2339 the BP was 126/76; 94/56 on 11/27/2016 at 0800; and 117/68 at 1515 (7 hours, 15 minutes later). Continued review revealed a BP of 98/61 on 12/04/2016 at 1508 and 136/68 on 12/04/2016 at 2009 (5 hours, 1 minute later). Review revealed on 12/06/2016 at 0627 the O2 saturation was 91 percent and 96 percent 12/06/2016 at 2043 (14 hours, 16 minutes later). Review failed to reveal a "Nursing Care Summary" or reassessment of the BP and O2 saturation following a noted change.

Interview on 11/29/2017 at 1330 with Administrative Staff #1 revealed staff are expected to complete a "Nursing Care Summary" according to the hospital's policy. Interview revealed vital signs are routinely obtained every shift, unless otherwise specified. Interview revealed on 11/27/2016 at 0800, the BP should have been rechecked "sooner than 5 hours later". Interview revealed on 12/06/2016 at 0627, the O2 saturation should have been rechecked "sooner". Interview confirmed a "Nursing Care Summary" was not available for review.

b. Medical record review on 11/28/2017 revealed Patient #6, a 80 year-old female was admitted to the hospital on 10/05/2017 after being found on an embankment by a neighbor. Review of the History and Physical (H&P) revealed the patient underwent "open reduction of a C5-C6 dislocation with anterior discectomy of C5-C6 for interbody fusion on 09/21/2017" and was transferred to the named facility for inpatient rehabilitation. Continued review revealed diagnoses included, but not limited to, difficulty swallowing; wrist pain with a possible fracture; hypotension; pain; depression; dementia; and dizziness. Review of the medication administration record (MAR) revealed an order for Midodrine (used to treat hypotension) 10 mg three time per day (tid) until 10/23/2017 when the does was decreased to 5mg tid.. Review revealed the patient's oxygen saturation (O2) was noted as 90 percent on room air, respiratory rate of 14, and a heart rate of 68. Review of the vital signs flowsheet revealed the patient's SBP ranged between 120-100, DBP 68-50; and O2 saturation 96-93 percent, consistently. Continued review of vital signs revealed on 10/10/2017 at 0231 the BP was 100/48; 89/47 at 1528, 90/52 at 1845 (3 hours, 7 minutes), and 95/46 at 0131 (6 hours, 41 minutes) on 10/11/2017. Review revealed on 10/15/2017 at 0553 the patient's O2 saturation was 91 percent on room air and 96 percent at 1517 (8 hours, 36 minutes later). Review failed to reveal a "Nursing Care Summary" or that vital signs and O2 saturations were reassessed immediately following a noted change.

Interview on 11/30/2017 at 1415 with Administrative Staff #1 revealed staff are expected to complete a "Nursing Care Summary" according to the hospital's policy. Interview revealed vital signs are routinely obtained every shift, unless otherwise specified. Interview revealed on 10/10/2017 at 1528 the BP and O2 saturation should have been rechecked "sooner for accuracy". Interview confirmed a "Nursing Care Summary" was not available for review.

c. Medical record review on 11/29/2017 revealed Patient #7, a 40 year-old male was admitted to the hospital on 11/24/2017 following a moped accident. Review of the H&P revealed the patient underwent "closed reduction and splinting of the left ankle" with a sling provided for the right upper extremity on 11/20/2017. He returned to the operating room (OR) on 11/22/2017 for "revision Open Reduction and Internal Fixation (ORIF) of the left medial malleolar ankle fracture as well as ORIF for right proximal humerus fracture" and was transferred to the named facility for inpatient rehabilitation. Review of the vital signs flowsheet revealed the patient's O2 saturation was 98-93 percent on room air, consistently. Review revealed on 11/26/2017 at 0556 the patient's O2 saturation was 91 percent on room air and 98 percent at 1529 (10 hours, 13 minutes later). Review failed to reveal a "Nursing Care Summary" or that the O2 saturation was reassessed immediately following a noted change.

Interview on 11/29/2017 at 1330 with Administrative Staff #1 revealed staff are expected to complete a "Nursing Care Summary" according to the hospital's policy. Interview revealed vital signs are routinely obtained every shift, unless otherwise specified. Interview revealed on 11/26/2017 at 0556, O2 saturation should have been rechecked "sooner than 10 hours later". Interview confirmed a "Nursing Care Summary" was not available for review.


















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2. Review of a Hospital Policy titled "Nursing Physical Assessment, Reassessment and Plan of Care", review date 04/30/2014, revealed "...POLICY STATEMENT: The (hospital name) Nursing Staff will perform an initial assessment and reassessment according to this policy....STANDARDS: Assessment....Assessment completed within 8 hours of admission....Reassessment....Reassessment will be performed at a minimum of every 24 hours and as needed as the patient's condition warrants....PHYSICAL ASSESSMENT:....9. INTEGUMENTARY Guidelines: assessment of temperature, presence of moisture, skin inspection for evidence of break down, turgor, and skin color. (Hospital identifying initials) - Complete the Skin Risk Assessment Scale/Braden Scale....to assess each patient's risk for development of skin breakdown by checking the appropriate selection in each category....Complete documentation. ..."

Review of a Healthcare system policy titled "Pressure Ulcer Prevention Guidelines and Specialty Bed Criteria", dated 10/19/2016, revealed "...POLICY:....B. Each inpatient at a (healthcare system name) facility will be assessed by the RN at admission and at least once every 12-hour shift for individual risk and/or actual pressure related skin breakdown. C. The nursing staff will implement the prevention protocol outlined below for any adult patient who scores 18 or less on the Braden Risk Assessment Scale....PROCEDURE: A. Prevention Protocol: 1. Assess patient, including: a. Risk factors for adult skin breakdown using the Braden Risk Assessment Scale....b. Current skin integrity (e.g. redness, maceration, cracking, ulcers, rash). ..."

Medical record review for Patient #9, on 11/29/2017, revealed the 84 year old was admitted to the hospital 09/28/2017 for rehabilitation after a Lumbar Laminectomy (back surgery) on 09/25/2017. Record review revealed admission diagnoses included gait dysfunction, post lumbar laminectomy, atrial fibrillation (rapid, irregular heart rate), anemia, thrombocytopenia (low platelet count that can cause problems with blood clotting) and dementia. Review of the Nursing Admission Assessment, dated 09/28/2017 at 1645, revealed "...Integumentary Symptoms....Dryness....Redness....Bruises....Overall Skin Assessment....Pt (Patient) has bilateral bruising, dryness, and scabbing on forearms. In groin area, closed, reddened area noted.... buttocks and back are reddened but blanchable (redness goes away when the skin is pressed)....Skin Temperature....Warm Skin Moisture....Dry Skin Turgor....Loose Texture....Thin.... Are Any Pressure Ulcers Present?....No .... Moisture Risk....Very Moist Sensory Perception....Very Limited Activity Risk....Chairfast Mobility Risk....Slightly Limited Nutrition Risk....Probably Inadequate Friction & Shear Risk....Potential Problem Skin Risk Assessment Score....13 points. ..." Record review failed to reveal any additional Skin (Braden) Risk Assessments completed after the initial admission assessment. Review of Skin/Wound/Invasive Line Assessments revealed assessment notations on 09/29/2017, at 1038, 1851, and 2253. At 1038, review revealed "Skin Turgor.... Loose", at 1851 "Overall Skin Appearance....Intact Skin Turgor....Loose", and at 2253 "Overall Skin Appearance....Intact....Appropriate for race Skin Turgor....Loose". Review did not reveal any specific assessments of the back or buttock area for skin condition or redness. On 09/30/2017 at 1001, assessment review revealed "Skin Turgor....Loose" and at 2324 revealed "Overall Skin Appearance....Appropriate for race Skin Turgor....Loose. Skin Assessment Label....Back Problem Incision Are any NEW pressure areas present?....No. ..." On 10/01/2017 at 1112, assessment review revealed "Overall Skin Appearance....Dry....Pale....Thin Skin Turgor....Tenting (does not spring back immediately) Skin Assessment Label....Back ? Problem Incision. ..." and on 10/02/2017 at 0000, review revealed "Overall Skin Appearance....Appropriate for race Skin Turgor....Loose Skin Assessment Label....Back ? Problem Incision ... ." Reviews from 09/30/2017 and 10/01/2017 did not reveal any specific assessment or notation related to the skin on the buttocks area. Review of a Skin/Wound/Invasive Line Assessment dated 10/02/2017 at 0400 revealed "...Skin Assessment Label o Buttocks Left Right ? Problem Pressure Area. ..." Review did not reveal the specific pressure area concerns. Skin Assessments from 10/02/2017 and 10/03/2017 failed to reveal a Skin Assessment Label for the buttocks area and failed to reveal any specific notation of the earlier concern. On 10/04/2017 at 1022, review of the assessment documentation again revealed " ...Skin Assessment Label o Buttocks Left Right ? Problem Pressure Area. ..." Further review failed to reveal the reason for the new addition of the Skin Assessment Label or the appearance of the pressure area. On 10/05/2017, review of Skin Assessment documentation revealed, at 0828, " ...Skin Assessment Label o Buttocks Left Right ? Discontinued Yes. ..." Record review did not reveal the reason for discontinuing the Skin Assessment Label. Further record review failed to reveal any documented skin assessments that specifically addressed the buttock area until 10/09/2017. On 10/09/2017 at 1357 a Wound Care note revealed an unstageable pressure ulcer noted on the buttocks, 1.7 cm (centimeters)(2.54 centimeters equals one inch) long by 2.3 cm wide. Skin Assessment review, on 10/09/2017 at 1413 revealed "Are there any NEW pressure areas present? o Yes If Yes, Add Location o L (left) buttock unstageable" and at 1414 "Skin Assessment Label o Buttocks Left ? Problem Pressure Area." Record review failed to reveal consistent skin assessments that specified the buttocks area or identified the pressure area concerns.

Interview with RN #2, on 11/30/2017 at 1040, revealed a Braden skin risk assessment was only done once during a patient's hospitalization, on admission. Interview revealed RN #2 was not certain of the hospital policy for reassessing skin, but thought it stated every 24 hours.

Interview with Administrative Staff (AS) #1, revealed the facility had two policies on skin and pressure ulcer prevention, one specific to the hospital and another for the healthcare system. Interview revealed the two policies conflicted in relation to Braden risk assessments and timing of skin and other reassessments. AS #1 stated the hospital is currently completing a Braden risk assessment only on admission. Interview further revealed that once the admission assessment showed the buttocks were reddened, AS #1 would have expected to see a skin assessment label related to this and to see the assessment completed and documented every 12-24 hours. Interview confirmed no further assessments were available in the medical record and revealed the facility had opportunities to improve.