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Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by failing to identify, investigate and document a patient representative's concerns for 1 of 1 (Patient #1) sampled patient reviewed for grievances out of a total sample of 5.
Findings:

Review of the hospital's policy titled Complaint/Grievance Process, Policy Number 1-4.5.0, revealed in part the following: Verbal complaints will be recorded on a confidential Complaint/Grievance Form by any staff member that takes the complaint. All verbal complaints that cannot be resolved immediately at the time of the complaint by the staff present will be addressed as a grievance. A response to a grievance (any action to begin the resolution process) within 24 hours...The hospital's Administrator/Assistant Administrator will be responsible for the review, investigation and resolve of all patient grievances. In its resolution to the grievance, the hospital will provide a written notice to the person filing the grievance within 10 calendar days.

On 04/12/16 at 1:00 p.m., interview with S1DON revealed that patient #1's daughter contacted her by phone on 03/16/16 complaining that a staff nurse accused the patient's family of administering extra medications to the patient. S1DON stated that the patient's daughter was upset by this accusation. S1DON further revealed that the patient's daughter also complained of another staff member who was encouraging the family to change the patient to a no code status. Further interview with S1DON revealed that the patient's daughter wanted the patient transferred to another hospital. S1DON stated that the patient was transferred to an acute care hospital on 03/16/16.

Further interview with S1DON at that time revealed that she was responsible for investigating all complaints and grievances. S1DON reported that she did not consider the daughter's concerns as a grievance. S1DON stated that she had reviewed patient #1's chart but had found no issues. S1DON had no documentation regarding the concerns made by patient #1's daughter.

On 04/13/16 at 11:15 a.m., interview with S1DON and S4Administrator confirmed that the complaints from patient #1's family member should have been considered a grievance. They confirmed that the hospital's grievance process had not been followed and a thorough investigation had not been completed.

Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 1 (Patient #3) of 2 patients (Patient #2, #3) out of a sample of 5 reviewed for the use of restraints.
Findings:

Review of the hospital's policy, Restraint or Seclusion, Policy Number 9-3.4.0, revealed in part, A care plan reflects the need for restraints or seclusion with goals and interventions.

Patient #3 was admitted to the hospital on 3/09/16 for Sepsis and Urinary Tract Infection. Review of her physician's orders revealed an order for soft upper extremity restraints from 3/11/16 to 3/14/16 due to the patient attempting to pull out catheters and IV (intravenous) lines.

Review of Patient #3's care plan revealed no problem, goals or interventions for the use of restraints.

An interview was conducted with S1DON on 4/13/16 at 10:30 a.m. She reported the patient being in restraints should have been included in her plan of care.

Based on record review and interview, the hospital failed to ensure each order for restraint use for non-violent or non-self-destructive patient was renewed as authorized by the hospital policy for 1 (Patient #2) of 2 patients (Patient #2 , #3) reviewed for use of restraints out of a sample of 5.
Findings:

Review of the hospital policy for Restraint or Seclusion, Policy Number:9-3.4.0, revealed in part, Orders for the management of the non-violent or non-self-destructive behavior will be renewed daily by an order from a physician or LIP.

Review of the patient's medical record revealed Patient#2 was admitted to the hospital on 2/19/16 for Acute Pancreatitis and Acute Respiratory Failure requiring Ventilatory Support. With further review of the medical record revealed he was placed in soft limb restraints to his upper extremities on 2/19/16 until 3/02/16.

Review of the restraint order for 2/26/16 revealed the order was not signed by the physician until 2/29/19 (3 days later) and the restraint order for 2/27/16 was not signed by the physician until 2/29/16 (2 days later).

An interview was conducted with S1DON on 4/13/16 at 11:05 a.m. She confirmed the restraints orders were not signed within the 1 day time period according to hospital policy.

Based on record review and interview, the hospital failed to ensure a RN supervised and evaluated the care of each patient as evidenced by:
1) failing to ensure an assessment was performed prior to and after administering a PRN (as needed) medication for 1 (Patient #1) of 2 (Patient #1, #2) patients reviewed for PRN medication administration
2) failing to ensure a patient was assessed prior to and after the administration of Narcan for 1 (Patient #1) of 1 patient reviewed for a suspected narcotic overdose
3) failing to assess and notify the physician of a patient's black stool, indicating blood loss, for 1 (Patient #1) of 1 sampled patient reviewed for a change in condition
4) failing to ensure a patient's pain level was documented at least every 4 hours while on a morphine drip for comfort for 1 (Patient #3) of 1 patient reviewed with a morphine drip
5) failing to assess and document notification of the patient's physician and interventions for a blood glucose of 39 mg/dl for 1 of 3 (Patient #1, #2, #5) patients reviewed for insulin administration per a sliding scale
6) failing to monitor a patient's weight daily as the physician ordered for 1 (Patient #3) of 2 (Patient #1, #3) patients reviewed for daily weights.
Findings:


1) Failing to ensure an assessment was performed prior to and after administering a PRN (as needed) medication

Review of the hospital policy titled Medication Administration, Policy Number 9-4.13.0, revealed in part that the reason for PRN medications and their effectiveness shall be documented on the PRN Medication form with the date, time, reason and response. If "see nurses' notes" is checked, refer to narrative nurses' notes for further explanation or clarification. Reason and response to pain medication will be documented on the "Pain Flow Sheet".

Review of the medical record for patient #1 revealed an admission date of 02/23/16 with diagnoses including right foot abscess, status post incision and drainage, and end stage renal disease. Review of a physician order dated 02/23/16 revealed an order for Hydrocodone/Acetaminophen (Norco) 7.5/325 every six hours as needed for moderate pain. Review of a physician order dated 03/03/16 revealed an order for Phenergan 25mg intravenous every 6 hours as needed for nausea and/or vomiting.

Review of the patient's medication administration record revealed the patient was administered PRN pain medication (Norco 7.5/325) on the following dates:
03/15/16 at 2:25 p.m
03/11/16 at 8:40 a.m.
03/10/16 at 1:20 a.m.
03/06/16 at 10:40 p.m.
03/01/16 at 7:40 p.m.
Further review of the record revealed no documented evidence that a pain assessment was performed prior to or after administering the above pain medication.

Further review of the patient's medication administration record revealed the patient was administered PRN Phenergan 25mg intravenous on the following dates:
03/12/16 at 4:25 p.m.
03/11/16 at 8:40 a.m.
03/10/16 at 7:20 p.m.
03/09/16 at 11:45 p.m.
03/07/16 at 9:05 a.m. and 10:35 p.m.
03/06/16 at 8:20 a.m.
Further review of the record revealed no documented evidence that an assessment was performed prior to or after administering the above medication.

On 04/12/16 at 1:00 p.m., S1DON reviewed patient #1's medical record. She confirmed that there was no documented evidence that an assessment was performed prior to or after administering the above medications. S1DON further confirmed that the hospital did not use the PRN Medication form as stated in their policy.

2) Failing to ensure a patients was assessed prior to and after the administration of Narcan

Review of the physician orders for patient #1 dated 03/16/16 revealed the physician ordered Narcan 0.4mg intravenous to be administered now and may repeat in 5 minutes times 2 if no response. Review of the medication administration record dated 03/16/16 revealed the patient was administered Narcan 0.4mg intravenous at 2:25 p.m., 2:30 p.m. and 2:35 p.m.

Review of the nurses notes dated 03/16/16 revealed no mention of the Narcan being administered. There was no documented evidence that an assessment was performed prior to of after the Narcan was administered.

On 04/12/16 at 1:00 p.m., interview with S1DON confirmed that there was no documented evidence in the record that the patient was assessed prior to or after the administration of Narcan.

On 04/13/16 at 8:15 a.m., an interview with S2RN revealed that she administered the Narcan to patient #1 on 03/16/16. She stated that the she had to administer all three doses and the patient still did not become fully arousable. S2RN reviewed the patient's record and confirmed that there was no documented assessment of the patient prior to or after administering the Narcan.

On 04/13/16 at 8:40 a.m., interview with S3LPN revealed that he was patient #1's nurse on 03/16/16. He stated that S2RN administered the Narcan to the patient and that the patient woke up and began talking after the second dose of the Narcan. S3LPN further confirmed that there was no documented assessment of the patient prior to or after the Narcan was administered.

3) Failing to assess and notify the physician of a patient's black stool, indicating blood loss

Review of the hospital policy titled Patient Assessment/Reassessment, Policy Number 9-1.1.0, revealed in part that any significant change in the patient's condition should elicit a reassessment of the patient (documented in the nurses notes) within one hour. The registered nurse is responsible for ensuring that the physician is notified of all significant changes in the patient's condition.

Review of the nurses notes for patient #1 dated 03/02/16 at 7:20 a.m. and at 9:30 p.m. revealed documentation that the patient vomited. Nurses notes dated 03/03/16 at 10:00 a.m. revealed that patient was on bed pan and soft black stool noted. On 03/03/16 at 5:00 p.m., nurses notes revealed the patient remained nauseated.

Further review of the record revealed the patient was transferred to an acute care hospital on 03/16/16 at 8:40 p.m. The patient's hemoglobin was 7.7 g/dL (normal is 12-15) and she was admitted to the intensive care unit

On 04/13/16 at 8:15 a.m., S2RN reviewed the patient's record and confirmed that she documented that the patient had black stool on 03/03/16. S2RN further revealed that was an indication of blood in the stool and should have been reported to the physician. S2RN confirmed that there was no documented evidence in the record that the patient was assessed and the physician notified of this change in condition.

On 04/13/16 at 10:00 a.m., interview with S1DON confirmed that the patient's change in condition should have been reported to the physician.

4) Failing to document a Patient #3's pain level at least every 4 hours while on a morphine drip.
Review of the hospital's policy for Analgesia and Sedation revealed in part, Documentation for a patient requiring frequent analgesia and/or sedation as part of their standard medical treatment, document as follows in the absence of a specific physician order: Pain flow sheet: level of pain will be documented at least every 4 hours and with every complaint of pain.
Patient #3 was a 86 year old female admitted to the hospital on 3/4/16 for Sepsis and Urinary Tract Infection. The patient was a DNR (Do Not Resuscitate) and a Morphine drip was ordered by the physician on 3/14/16 for comfort measures.
Review of the Physician's order on 3/14/16 at 1030 revealed, Make pt a comfort care per family request. DC labwork. DC all meds except prn IV ativan and prn IV hydralazine. Start morphine drip at 1 mg/hour.
Review of the Physician's order on 3/15/16 at 0330 revealed Clarification on Morphine drip order on 3/14/16: Start Morphine drip at 1 mg/hour titrate for comfort.
Review of the IV Titration Flow Sheet and the Pain Flow Sheet dated 3/15/16 until 3/18/16, (the date the Morphine drip was discontinued), revealed no pain level assessed on the patient to determine the need to titrate the morphine dose except on 3/18/16 at 1330 and 1400 when there was documentation the patient was moaning and the morphine drip was increased.
An interview was conducted with S1DON on 4/13/16 at 10:45 a.m. She reported while the patient was on the morphine drip for comfort, her pain levels should have been documented. When questioned if the patient was alert enough to indicate her pain level, S1DON reported the patient was alert enough at first then the nurses should have documented the patient's pain indicators such as increase heart rate, grimacing, and moaning.

5) Failing to assess and document notification of the patient's physician for a blood glucose of 39 mg/dl.
Patient #5 was admitted to the hospital on 4/04/16 for Type 1 Diabetes and Diabetic Foot Disease.
Review of the patient's Physician's Orders, dated 04/05/16 revealed FSBG ac and hs and 3:00 a.m., No extra insulin at hs or 3:00 a.m.
If < 80 hypoglycemic protocol
81-180-0
181-220-2 units of Apedra
221-260-4
261-300-6
>300- 8

Review of the Patient #5's Diabetic Record dated 4/08/16 at 11:30 a.m. revealed a blood sugar of 39 and a repeat blood sugar at 1:50 p.m. of 133.
Review of the Nurse's notes for 4/08/16 revealed no assessment of the patient during or after his blood sugar of 39 mg/dl, no indication the physician was notified and no documentation of the interventions that were implemented for the patient's low blood glucose.
An interview was conducted with S1DON on 4/13/16 at 11:00 a.m. She reported, after review of the patient's medical record, the nurse failed to document her assessment, all her interventions and notification of the patient's physician.

6) Failing to monitor a patient's weight daily as ordered by the physician
Review of the medical record for Patient #3 revealed he was admitted on 2/19/16 for Acute Pancreatitis and Acute Respiratory Failure.
Review of the Physician Admit Orders from 2/19/16 revealed an order for Daily weights.
Review of Weight Flow Sheet revealed the patient's weight was monitored 9 days out of a total of 24 days he was in the hospital, less than half the time he was in the hospital.
An interview was conducted with S1DON on 4/13/16 at 10:30 a.m. She confirmed the patient's weight was not monitored daily as ordered by the physician.



26351

Based on record review and interview, the hospital failed to ensure the RN developed and kept current a nursing care plan for each patient as evidenced by failing to have an accurate nursing care plan that included a plan for all conditions for which the patient was being treated for 2 (Patient #1, #2) of 5 patient records reviewed for nursing care plans from a total sample of 5 patient records.
Findings:

Review of the hospital policy for The Nursing Process-Care Planning revealed in part, Purpose: to provide each patient with an individualized plan of nursing care...The nursing plan of care provides a collaborative/systematic method of individualized care that focuses on the patient's response to an actual or potential alteration in health based on patient assessment.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 03/23/16 with diagnoses including diabetes mellitus and end stage renal disease on dialysis. The record revealed that the physician ordered capillary blood glucose checks before meals and at bedtime with Humulin R sliding scale insulin. The record also revealed the patient received hemodialysis three times per week and was on a one liter per day fluid restriction.

Review of the medical record revealed the patient began complaining of nausea and/or vomiting on 03/03/16 and the physician ordered Phenergan 25mg intravenous every six hours as needed. Documentation revealed that between 03/03/16 and discharge on 03/16/16, the patient received 9 doses of Phenergan. On 03/13/16, a gastrointestinal physician was consulted and a gastric emptying study was ordered.

Review of Patient #1's nursing care plan revealed no documented evidence that a nursing care plan was developed for diabetes mellitus, end stage renal disease requiring dialysis or the patient's issues related to nausea/vomiting.

In an interview on 04/12/16 at 1:00 p.m., S1DON confirmed the nursing care plan did not include a plan for diabetes mellitus, end stage renal disease requiring dialysis or nausea/vomiting. She indicated that the patient's medical conditions warranted these care plans to be developed and implemented.


Patient #2
Patient #2 was admitted to the hospital on 2/19/16 for Acute Pancreatitis with Acute Respiratory Failure requiring ventilatory support and Acute Renal Failure requiring dialysis. He had a tracheostomy and a PEG tube placed and they were removed prior to discharge from the hospital on 3/14/16.

Review of his Care Plan revealed no interventions for his Problem for Impaired Verbal Communications and no goals or interventions for Ineffective Breathing Patterns. The patient was not care planned for having a PEG tube for feedings, TPN or having to be administered insulin due to the Acute Pancreatitis.

An interview was conducted with S1DON on 4/13/16 at 11:00 a.m. She confirmed the patient's care plan did not address all the patient's current medical issues.

26351

Based on record review and interview, the hospital failed to ensure drugs and biological's were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and as directed by hospital policy for 2 (Patient #1, #5) of 3 patients (Patient #1,#2, #5) reviewed for insulin administration per sliding scale.
Findings:

Review of the hospital policy titled; Insulin Administration, Policy Number 9-4.11.0, revealed in part, Purpose: To assure proper administration of subcutaneous and intramuscular insulin...Moreover the treatment of hyperglycemia with insulin confers advantages in a variety of hospitalized patients, with and without diabetes. Using insulin to maintain glucose levels at <200 mg/dL leads to improved morbidity and mortality, fewer infections, and more rapid wound healing...2rd nurse verification: Two licensed nurses shall verify the following prior to insulin administration: the physician's order, type of insulin, right patient, dosage route, and time.

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 02/23/16 with diagnoses including diabetes mellitus. Admit orders revealed the physician ordered capillary blood glucose checks before meals and at bedtime with Humulin R sliding scale insulin subcutaneously as needed. The order revealed the following sliding scale:
60-150= 0 units
151-200= 2 units
201-250= 4 units
251-300= 6 units
301-350= 8 units
351-400=10 units

Review of the Diabetes Record flow sheets revealed the following:
03/15/16 at 9:00 p.m., blood glucose 212, no sliding scale insulin administered
03/11/16 at 11:30 a.m., blood glucose 185, no sliding scale insulin administered
03/09/16 at 7:30 a.m., no blood glucose result documented (blank)
03/09/16 at 4:30 p.m., no blood glucose result documented (blank)
03/09/16 at 9:00 p.m., blood glucose 182, no sliding scale insulin administered
03/07/16 at 7:30 a.m., blood glucose 154, no sliding scale insulin administered
03/07/16 at 9:00 p.m., blood glucose 176, no sliding scale insulin administered

Review of the medication administration records and nurses notes for the above dates revealed no documented evidence that the patient received sliding scale Humulin R insulin as ordered by the physician.

On 04/13/16 at 10:00 a.m., S1DON reviewed patient's #1's record. She confirmed that there was no documented evidence that the patient recieved sliding scale Humulin R insulin as ordered by the physician.

Patient #5
Patient #5 was admitted to the hospital on 4/04/16 for Type 1 Diabetes and Diabetic Foot Disease.

Review of the Physician Orders revealed an order on 4/05/16 for FSBG ac and hs and 3:00 a.m., No extra insulin at hs or 3:00 a.m.
If < 80-hypoglycemia protocol
81-180- 0
181-220 -2 units of Apedra
221-260- 4
261- 300-6
>300-8

Review of the patient's Diabetic Record on 4/08/16 at 7:30 a.m. revealed a blood glucose of 181, with a "0" in the insulin box indicating no insulin was administered to the patient. With review of the physician's insulin sliding scale order, 2 units of Apedra should have been administered to the patient.

An interview was conducted with S1DON on 4/13/16 at 10:35 a.m. She confirmed 2 units of Apedra should have been administered to the patient.