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Based on review of hospital policies and the grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Complaint/Grievances Process," with an issue date of12/01/98, last revision date 7/01/10 defined a patient grievance as "a formal or informal written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS hospital Conditions of Participation". The policy provided time frames for investigation and resolution of grievances; stipulated that a written response with the required information would be provided to the complainant; and stipulated the Director of Quality Management and/or Director of Clinical Services will investigate the grievance and review with the Chief Executive Officer . The policy further provided for complaint and grievance review through the governing body. The hospital failed to follow hospital grievance policy in two (3,4)of three (3,4,5) grievances reviewed.

2. Grievance #3 involved nursing care and allegations the nurse " just wanted to drug" the patient. The charge nurse removed the nurse from the care of the patient but did not remove the nurse from caring for other patients. The hospital identified the complaint as a grievance but did not provide a written response to the complainant. The hospital could not provide documentation of an investigation. The hospital could not provide documentation the nurse had been counselled.

3. Grievance #4 involved nursing care and nursing staff being "mean" to a patient after the patient fell. The complaint was identified as a grievance. A letter was sent to the complainant which indicated staff members have been counselled and the Chief Nursing Officer (CNO) will follow up with employees. The hospital did not have documentation the CNO followed up with employees as stated in the letter. The hospital did not send a follow up letter once the CNO followed up with employees.

4. The above information was addressed with administration in an exit conference. No further documentation was provided.

Based on review of policy and clinical records, the hospital did not ensure that patient controlled anesthesia (PCA) are administered according to the approved procedures. This occurred in two (3,4) of two patients selected for review.

Findings included:

Policy Review:
Pharmacy policy "Patient Controlled Analgesia (PCA) stipulates in policy "2b. the nurse caring for the patient shall have a thorough understanding of the proper use of the PCA. d. The nurse shall assess and record the patient's pain score, respiratory rate, and sedation score on both the PCA flowsheet and the 24 Hour Flow Sheet." Further the policy stipulates "3. A witness is required to sign the PCA flowsheet for the following actions: a . insertion of the PCA syring or bag in the PCA pump as well as primin of the PCA infusion tubing, b. any dose change on the PCA pump, c. to waste any remaining narcotic in the PCA syringe or bag, d. to record the four hour total and "clear" the pump.

The PCA flowsheet used by nursing to document administration of PCA medications instructs staff to: 1. Use a new flow sheet for each new syringe, (2) documentation of initiaition, every 4 hours, at shift change, whenever orders change, and when the PCA is discontinued. (3) A cosignature is required at shift change, on initiation (one must be a registered nurse RN), and with any programming changes/corrections (one must be RN). 4. Zero pump with each new syringe only.

Further review of these records found the following:


1. Three of five (K, J, H) nursing personnel files reviewed for PCA training did not include any training on documentation and administration of PCA medications. The hospital did not follow policy.

2. Patient #2's medical record indicated the patient received a PCA. The PCA flowsheet indicated nursing documented 27 milliliters (ml) left to count in the syringe at 0000. There was no documentation on the flowsheet of the amount of medication infused. The next documentation on the flowsheet was wastage at 0525 for 16 mls. There was no documentation indicating medication was infused between 0000 and 0525. There was no accounting for 11 mls between the time of the last infusion documentation to wastage.

3. Patient #3's medical record indicated the patient received a PCA. The PCA flowsheets were not completed per policy. On several dates the PCA syringe was wasted without cosignature. On several dates amounts infused were not documented. On several occasions the PCA syringe was documented as changed and there was no cosignature. Two days of PCA administration did not have the "initial syringe setup" documented. Multiple flowsheets did not include correct documentation of "total given per pump". Multiple flowsheets documented more medication given than the PCA held. Multiple flowsheets did not have a minimum every four hour documentation. Multiple sheets had discrepancies in administered medications and wasted medications

Based on review of records and interviews with hospital staff, the hospital does not ensure that current and accurate records are maintained of the receipt and disposition of all scheduled drugs in accordance with Federal and State laws. The pharmacy does not maintain records of scheduled drugs with sufficient detail to follow their flow from their entry into the hospital through dispensation and administration or wastage in a readily retrievable manner. The hospital does not ensure that the records are in order and all scheduled drugs are maintained and reconciled.

Findings:

1. The pharmacy does not maintain narcotic administration records of scheduled medications dispensed to the hospital areas that document the following: 1. date 2. patient 3. person administering the drug 4. the physician 5. the dose of the drug and 6. wastage, if any with identification of the persons who wasted and witnessed the wastage in a readily retrievable manner.

2. According to Staff E, drug records are only maintained in the automated drug dispensing system for 30 days and then they are purged.

3. When the surveyor asked to see the drug administration records for patient #3's patient controlled analgesia (PCA) the pharmacy could not retrieve the information.

4. There was no evidence provided that the pharmacy reconciles the PCA schedule drugs to determine if what is dispensed is what is administered or wasted.

5. Patient #3's medical record indicated the patient received a PCA. The PCA flowsheets were not completed per policy. On several dates the PCA syringe was wasted without cosignature. On several dates amounts infused were not documented. On several occasions the PCA syringe was documented as changed and there was no cosignature. Two days of PCA administration did not have the "initial syringe setup" documented. Multiple flowsheets did not include correct documentation of "total given per pump". Multiple flowsheets documented more medication given than the PCA held. Multiple flowsheets did not have a minimum every four hour documentation. Multiple sheets had discrepancies in administered medications and wasted medications.

Based on record review and interviews with staff, the hospital does not ensure that current and accurate records are kept of the receipt and distribution of all scheduled drugs and scheduled drugs are controlled and distributed in accordance with Federal and State regulations.

Findings:

1. Pharmacy policy "Patient Controlled Analgesia (PCA) stipulates in policy "2b. the nurse caring for the patient shall have a thorough understanding of the proper use of the PCA. d. The nurse shall assess and record the patient's pain score, respiratory rate, and sedation score on both the PCA flowsheet and the 24 Hour Flow Sheet." Further the policy stipulates "3. A witness is required to sign the PCA flowsheet for the following actions: a . insertion of the PCA syring or bag in the PCA pump as well as primin of the PCA infusion tubing, b. any dose change on the PCA pump, c. to waste any remaining narcotic in the PCA syringe or bag, d. to record the four hour total and "clear" the pump

2. Patient #2, 3's medical record indicates orders for a patient controlled analgesia (PCA). Both medical records included PCA flowsheets. The PCA flowsheets instruct staff to 1. Use a new flow sheet for each new syringe, (2) documentation of initiaition, every 4 hours, at shift change, whenever orders change, and when the PCA is discontinued. (3) A cosignature is required at shift change, on initiation (one must be a registered nurse RN), and with any programming changes/corrections (one must be RN). 4. Zero pump with each new syringe only.

Patient #2's medical record indicated the patient received a PCA. The PCA flowsheet indicated nursing documented 27 milliliters (ml) left to count in the syringe at 0000. There was no documentation on the flowsheet of the amount of medication infused. The next documentation on the flowsheet was wastage at 0525 for 16 mls. There was no documentation indicating medication was infused between 0000 and 0525. There was no accounting for 11 mls between the time of the last infusion documentation to wastage.

Patient #3's medical record indicated the patient received a PCA. The PCA flowsheets were not completed per policy. On several dates the PCA syringe was wasted without cosignature. On several dates amounts infused were not documented. On several occasions the PCA syringe was documented as changed and there was no cosignature. Two days of PCA administration did not have the "initial syringe setup" documented. Multiple flowsheets did not include correct documentation of "total given per pump". Multiple flowsheets documented more medication given than the PCA held. Multiple flowsheets did not have a minimum every four hour documentation. Multiple sheets had discrepancies in administered medications and wasted medications

3. The afternoon of 9/27/11 Hospital Staff E reviewed PCA flow sheets with surveyors. Staff E told surveyors she did not reconcile wastage, she thought nursing did that. Staff E told surveyors she only looked for initials and did not realize the nursing staff were not documenting appropriately. Staff E also told surveyors she did not check to see if the licensure requirements stipulated in the policy were followed. Staff Estated she did not check to see if the totals documented matched the wastage documented.

4. No records were available to show the pharmacist is responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and reconciled. The hospital did not have Narcotic administration records to show the movement of scheduled drugs from point of entry until administered, wasted or returned to the manufacturer.

5. Hospital Staff E stated on the afternoon of 9/27/11 that the they do not keep the records from the automated drug dispensing machine where the scheduled drugs are stored past 30 days.

Based on a review of policies and procedures, medical records, interviews with the pharmacist and administrative staff, the hospital failed to ensure the nurses administering patient controlled analgesia followed the correct protocols for medication administration. In two of two (2,3) patients receiving patient controlled analgesia the nurse did not follow the accepted standards of practice for medication administration or follow hospital policy.

Findings:

1. Two (2,3) of two patients receiving patient controlled analgesia (PCA) did not have complete documentation on the PCA flow sheet(s). Staff did not document according to policy or flowsheet instruction.

2. Three of five (K,J,H) personnel files did not indicate nursing staff had training on PCA administration, wastage, or documentation. In two of two pharmacy files there was no evidence the pharmacy staff had current training on the hospital policy for patient controlled analgesia.

3. There was no evidence provided to surveyors the pharmacy had oversight over PCA (controlled narcotic) administration and that when discrepancy in documentation was found an incident report was generated. No records were available to show the pharmacist is responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and reconciled. The hospital did not have Narcotic administration records to show the movement of scheduled drugs from point of entry until administered, wasted or returned to the manufacturer. Hospital Staff E stated on the afternoon of 9/27/11 that the they do not keep the records from the automated drug dispensing machine where the scheduled drugs are stored past 30 days.

4. In an interview on 9/27/2011 Staff E told surveyors she told Staff B (DON) there were problems with PCA administration because the facility does not have them very often. Staff E could not provide surveyors evidence the PCA issues had been discussed in committees or reviewed at Pharmacy and Therapeutics.