HospitalInspections.org

Based on facility policy review, medical record review, review of a facility document, and interview, the facility failed to investigate a grievance for 1 patient (#4) 1 patient reviewed for grievances of 14 medical records reviewed.

The findings included:

Review of facility policy Complaint and Grievance Process dated 10/1/17 revealed "...3. The patient and the patient's representative may inform the Hospital of a complaint or grievance verbally or in writing. 4. The Hospital staff member receiving the complaint or grievance will initiate the complaint/grievance form...8. The Hospital staff member shall notify his/her supervisor. The complaint/grievance form is then forwarded to the Hospital's Director of Quality Management. The Director of Quality Management shall enter the information into Lotus. The Director of Quality Management shall notify the Chief Executive Officer [CEO] when a grievance has been received and logged in the [computer] database. 9. The Director of Quality Management [DQM] and/or Chief Nursing Officer [CNO] will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO. The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint. If the grievance will not be resolved or the investigation completed within 7 days, the hospital shall inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up with a written response in a stated number of days...12. The DQM, along with the CEO, will prepare a written response to the patient's or patient representative's grievance. The written response is required whether or not a meeting was held to discuss the investigation with the patient or the patient's representative...13. The written response must contain the following: a. A description of the issues raised by the grievance. b. A description of the steps taken to investigate the issue. c. The date the grievance was resolved and what steps were taken to resolve the grievance. d. The name of a contact person at the hospital that the patient can call with additional questions..."

Medical record review revealed Patient #4 was admitted to the facility on 2/28/18 for Sepsis (a life threatening complication of an infection) and was discharged from the facility on 3/23/18.

Medical record review of a physician's History and Physical dated 2/28/18 revealed "...with a past medical history significant for Devic syndrome [inflammatory condition of the protective covering of the spinal cord and optic nerve] as well as paraplegia [paralysis of the trunk, legs, and pelvic organs], CVA [Cerebrovascular Accident/stroke] and pressure wounds to the sacrum and hip who presented to [named acute care hospital] on 2/9/18 with a 2 day history of fever, chills, decreased urine output and decreased p.o. [by mouth] intake..."

Review of a facility document dated 3/19/18 revealed the CEO had a typed list of concerns from Patient #4's sister. Further review revealed "...spoke to...sister to [Patient #4]...about concerns she had with the patient's care...[sister] also stated she asked the nurse...to change the patient's wound dressing because it was soiled. The nurse stated she had not changed a dressing at our hospital and would have to ask but no one ever changed the dressing on day shift. She stated the dressing was changed on night shift...This past weekend, patient had dried stool on her wound dressing and stated the dressing should have been changed because it was soiled...stated staff members come in and push lights on the system and do not turn the patient...she has been disappointed in the..."

Interview with the CEO on 6/27/18 at 9:05 AM, in the Director of Nursing (DON) office, revealed "...on 3/19/18 I spoke to the sister...to the patient...about her [Patient #4's] care...concern was that the patient was given Potassium [electrolyte]. Patient told the nurse she was having issues and the nurse issued the potassium 4 hours later...she [sister] asked the nurse to change the wound dressing because it was soiled...she [nurse] didn't know where all the supplies were and didn't feel comfortable [changing dressing]...I sent an email to the Director of Quality Management and I don't recall anything else of what was done..."

Interview with the Director of Quality Management on 6/27/18 at 10:35 AM, in the DON's office, revealed "...I received an email...I don't recall the email...I read the email Monday [6/25/18] after he [CEO] resent it [email] to me...it [complaint/grievance] was not entered into the [computer] system..." Further interview confirmed "...there was no investigation or a written letter sent..."

Interview with the Director of Quality Management on 6/27/18 at 10:55 AM, in the DON's office, confirmed the facility failed to investigate a grievance and the facility failed to follow facility policy.

Based on facility policy review, facility Bylaws review, medical record review, and interview, the facility failed to obtain a physician order prior to medication administration for 1 patient (#4) of 14 patients reviewed.

The findings included:

Review of facility policy Medication Administration Record - Paper dated 10/2013, revealed "...9. Medication orders are to be checked at the end of each shift against the Physician's Order Sheet(s) for accuracy in transcription. All physician orders are to be checked and additions, corrections, and/or deletions made as indicated..."

Review of facility Medical Staff Bylaws of Select Specialty Hospital - Tricities, Inc. dated 2018, revealed "...5. A practitioner's routine orders...shall be reproduced in detail on the order sheet of the patient's record, dated and signed by the practitioner...9. Standing orders and/or instruction sheets...All standing orders and/or instruction sheets must be signed and dated by the responsible practitioner when utilized, as required for all orders for treatment..."

Medical record review revealed Patient #4 was admitted to the facility on 2/28/18 for Sepsis (a life threatening complication of an infection) and was discharged from the facility on 3/23/18.

Medical record review of a Frequent Monitoring/Critical Medication Flowsheet dated 3/9/18 revealed Patient #4 received 39 doses of Levophed (medication to treat life-threatening low blood pressure) 8 milligram (mg)/250 milliliter (ml). Continued review revealed the patient received 31 doses of Levophed on 3/10/18 and 29 doses on 3/11/18.

Medical record review of Physician's Orders dated 3/9/18 - 3/11/18 revealed no physician orders for Levophed.

Interview with the Director of Quality Management on 6/28/18 at 11:00 AM, in the DON's office, confirmed the facility failed to obtain a physician's order prior to administering Levophed to Patient #4.

Based on facility policy review, facility Bylaws review, medical record review, and interview, the facility failed to ensure medical records were accurate for 1 patient (#4) of 14 medical records reviewed.

The findings included:

Review of facility policy Assessment and Reassessment of Patients dated 1/1/18 revealed "...Patients are reassessed to determine their response to treatment, when a significant change occurs in patient condition, when a significant change occurs in the patient's diagnosis or based on patient/need request for treatment and/or medication...Assessment and reassessment data will be documented in the patient's medical record...Reassessment is a documented description of the patient's response/status relative to medical and/or nursing interventions, effectiveness of interventions, resolution of patient problems/needs..."

Review of facility policy Change in Patient Condition: Early Recognition and Intervention dated 4/1/18 revealed "...6. Identify/suggest Rapid Response Team protocols...Significant Change in Condition...1...Any single finding does describe a significant change in condition and requires Assessment, Documentation, and Notification...Change in mental status, level of consciousness (LOC), neurological status...Rapid Response Team Activation Sequence: 1. Recognition of a worrisome or acute change in condition by bedside caregiver, family member, or other. 2. Rapid assessment completed by primary caregiver. 3. Activation of Rapid Response Team (RRT). 4. RRT arrives at bedside...performs assessment including, medication and lab results review. 5. Appropriate RRT protocols initiated by team and orders placed on patient record...6. Attending physician and/or appropriate consultants notified...7. Assessment, interventions, and physician communication documented...It is the Charge Nurse's responsibility to ensure that the attending physician is notified expeditiously...Documentation...1. The complete assessment should appear on the nursing flow sheet. The change in condition and physician communication should be documented in the clinical notes...2. When a Rapid Response Team (RRT) is initiated, utilize the RRT Response Record/EMR [electronic medical record] to document assessment data, interventions and physician communication..."

Review of facility Medical Staff Bylaws of Select Specialty Hospital - Tricities, Inc. dated 2018, revealed "...C. Medical Records...1. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current for each patient. This record shall be identification data, medical history, physical examination, diagnostic...clinical observations...3...the patient's clinical problems should be clearly identified in the progress notes...Progress notes shall be written in an appropriate frequency to document monitoring of the patient's current condition...All orders, including verbal orders, must be dated, timed and authenticated by the prescribing physician, a licensed independent practitioner...The physician's order must be written clearly, legibly and completely...All standing orders and/or instruction sheets must be signed and dated by the responsible practitioner when utilized, as required for all orders for treatment..."

Medical record review revealed Patient #4 was admitted to the facility on 2/28/18 for Sepsis (a life threatening complication of an infection) and was discharged from the facility on 3/23/18.

Medical record review of a physician's Admitting History and Physical dated 2/28/18 revealed "...with a past medical history significant for Devic syndrome [inflammatory condition of the protective covering of the spinal cord and optic nerve] as well as paraplegia [paralysis all or part of the trunk, legs, and pelvic organs], CVA [Cerebrovascular Accident/stroke] and pressure wounds to the sacrum and hip who presented to [acute hospital] on 2/9/18 with a 2 day history of fever, chills, decreased urine output and decreased p.o. [by mouth] intake..."

Medical record review of a 24 Hour Patient Record and Plan of Care dated 3/9/18 at 8:00 AM revealed "...Nurses Progress/Narrative Notes...[temperature] 102.6...skin red, rashy [rash], hot to touch...eyes open...[no response] to questions...CN [charge nurse] notified of change of condition..." Continued review revealed the RRT was called at 10:45 AM (2 hours and 45 minutes after change of condition assessment).

Medical record review of a RRT Response Record dated 3/9/18 revealed "...RRT called: Date 3/9/18...Time 10:45 [AM]...Reason Called...Change in mental status..."

Interview with the Nurse Practitioner (NP) #1 on 6/26/18 at 2:55 PM, in the Director of Nursing (DON) office, revealed "...she [Resident #4] spiked a fever of 106...she had altered mental status...she had a reaction from her antibiotic...she had a change in antibiotics...the day before [3/8/18]...Infection Disease was brought on board and changed the antibiotic...I don't know who found her...I don't remember if she [Patient #4] was unresponsive...I don't know if the rapid response started at 8:00 AM or 10:45 AM...the rapid response was called at 10:45 AM...I don't know if she had another change in condition from 8:00 AM to 10:45 AM...I don't know who contacted me...I didn't document anything about the Rapid Response..."

Interview with the Respiratory Therapist Supervisor on 6/26/18 at 3:05 PM, in the Director of Nursing (DON) office, revealed "...I remember the rapid response...I did attend [RRT]...I did not make a note about the rapid response...I should have made a note..."

Telephone interview with Registered Nurse (RN) #1 on 6/28/18 at 8:00 AM, revealed "...I was assigned [Patient #4] on 3/9/18...the patient was running a temperature of 102.6 axillary [under the arm] and she would not respond when I asked her questions so I went and told the charge nurse...myself, charge nurse, and 3 other nurses went back to the patient's room to try to figure out what was going on with the patient..." Continued interview confirmed "...we are not good at calling a rapid response...we called a rapid response when we realized there was a change in her condition...the rapid response actually started at 8:00 AM...we didn't call it [rapid response] until 10:45 [AM]...we [RN #1, RN #2, and 3 other nurses] were trying to get an IV [intravenous] line because her [Patient #4] IV wouldn't work...we tried 7 to 10 attempts to get an IV and I finally got one [IV] in her foot...I didn't chart anything...didn't chart anything in the nurses notes for the rest of the shift...I should have [charted]...we notified [NP #1] at 10:46 [AM]...I don't know when the rapid response ended...I signed the [RRT form] at 12:50 PM..."

Telephone interview with RN #2 (charge nurse) on 6/28/18 at 9:06 AM, revealed "...I see in the notes we didn't call the rapid response when it started [8:00 AM]...we were in the room attempting to start an IV...we didn't chart it...we kept the Nurse Practitioner [#1] informed the whole time...we didn't chart it..."

Interview with the Director of Quality Management on 6/28/18 at 10:55 AM, in the DON's office, confirmed the facility failed to ensure Patient #4's medical record was complete and accurate and failed to follow facility policy.