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Based on policy review, document review and interview, it was determined the facility failed to ensure their grievance process identified, documented and resolved grievances, responded to the complainant, and tracked and monitored grievances to prevent recurrence.

The findings included:

1. Review of the facility Patient Grievances policy revealed, "Policy: patients should have reasonable expectations of care and services received. Patients have the right to voice concerns either verbally or in writing when their expectations are not met ...a patient grievance is any complaint, problem, or concern that patients or family members may have regarding the services they are receiving that cannot be resolved promptly or involve physician care, treatment or behavior. A patient complaint is any complaint, problem, or concern that patients or family members may have regarding services that is resolved promptly... complaints received verbally will be triaged appropriately... complaints will be entered into a database for tracking purposes... investigation will be initiated by involving responsible parties... documentation is maintained in the Patient Complaint Database... Electronic documentation is maintained... issues concerning patients currently in the hospital (inpatient and outpatient) that do not involve physician issues will be considered complaints and will be handled and resolved with the patient/family within 24 hours... appropriate documentation of all complaints will be maintained to provide a basis for identifying patterns of problems for preventive action. Documentation serves as a profile of the hospital experience from the patient's viewpoint and pinpoints negative trends and problem areas. It also provides the basis for more responsive policies and procedures..."

2. During tour on 5/12/14 at 10:30 AM Random Patient #3 stated, "...They don't come quick...Have to wait...I've told them about it already..."

3. During tour on 5/12/14 at 10:25 AM, observations revealed Patient #5 was sitting in a chair, had a tracheostomy and communicated with a dry erase board.
During an interview, the patient was asked if there were any problems or concerns regarding his/her care. Patient #5 wrote the following answer on the dry erase board, it sometimes takes the staff "10 - 20 minutes to come when push button [call light]."

4. During an interview on 5/13/14 at 1:40 PM the Administrator was asked to review the grievance/complaint process and any grievance complaints that have been filed for the last 2 months. The Administrator stated the Quality Manager is responsible for the grievance complaint process.

During an interview on 5/13/14 at 1:50 PM the Quality Manager (QM) stated she tracks the grievance complaints on a form in the computer. The Quality Manager was unable to provide the documented tracking form for the year 2014.
The QM stated she was aware of Random Patient #2's complaint that staff took too long to answer the call lights. The QM stated she told Random Patient #2 not to, "just try to see how long it takes" to answer the call light, if they had to call the second time, to ask for the charge nurse.

During an interview on 5/13/14 at 2:00 PM the Nurse Manager (NM) stated she was aware of the call light complaint from Random Patient #3. The NM stated Random Patient #3 talked to her about waiting for the call light to be answered and they called several times and no one came.

There was no documentation to demonstrate the grievance policy was followed and effective interventions implemented to resolve the ongoing grievance regarding slow response to call lights.

Based on policy review, record review and interview, it was determined the Registered Nurse (RN) ensure the assigned nursing staff demonstrated adherence to the facility policy for assessment and addressing pain control for 3 of 6 (Patients #1, 4, and 6) sampled patients.

The findings included:

1. Review of the facility, Pain Management Guidelines revealed, "Purpose: to establish a process for pain management. Policy: the patient's right to pain management is recognized, respected, and supported... the patient's pain status is assessed, but is not limited to: 1. each complete patient assessment per patient care area policy... each compliant of pain; 3. when pain medication or dosage is changed; 4. when pain interventions are provided... Pain assessment includes: a. a pain intensity rating scale appropriate for the patient population b. location c. quality d. onset e. duration f. aggravating/relieving factors g. relieving medications... A pain intensity scale is used to rate pain. The appropriate pain scale is used to rate pain based on patient's age, cultural or language barriers or cognitive impairment... allow sufficient time for the patient to respond... Alternate methods of pain management are implemented based on the plan of care for patients who are receptive to such interventions. These include, but are not limited to, repositioning, hot/cold therapy, relaxation, music and massage... 1-3 mild pain 4-6 moderate pain 7-10 severe pain...the reassessment is documented... the nurse continues to intervene until an acceptable level of pain is obtained as determined collaboratively by the patient, family and caregiver... When appropriate pain management is not achieved, the licensed independent practitioner is contacted..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 4/4/14 with diagnosis of Respiratory Failure.
Record review revealed the patient's pain was rated on a 0 to 10 scale, with 10 being the worst pain, and included the following:

On 5/7/14 at 1:07 AM, Patient #1 had pain at a level of 7 and lortab was administered. At 5:21 AM, she had pain at a level of 7 and lortab was administered. At 9:27 AM, she had pain at a level of 6 and dilaudid was administered. At 1:02 PM, she had pain at a level of 8 and dilaudid was administered. At 4:16 PM, she had pain at a level of 7 and dilaudid was administered. At 8:47 PM, she had pain at a level of 7 and dilaudid was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/8/14 at 5:55 AM, Patient #1 had pain at a level of 7 and dilaudid was administered. At 9:27 AM, she had pain at a level of 8 and dilaudid was administered. At 4:44 PM, she had pain at a level of 8 and dilaudid was administered. At 8:21 PM, she had pain at a level of 7 and dilaudid was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/9/14 at 10:18 AM, Patient #1 had pain at a level of 8 and dilaudid was administered. At 1:44 PM, she had pain at a level of 7 and dilaudid was administered. At 8:01 PM, she had pain at a level of 8 and dilaudid was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/10/14 at 6:43 AM, Patient #1 had pain at a level of 6 and dilaudid was administered. At 4:01 PM, she had pain at a level of 8 and dilaudid was administered. At 9:38 PM, she had pain at a level of 7 and dilaudid was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/11/14 at 8:45 AM, Patient #1 had pain at a level of 8 and lortab was administered. At 8:18 PM, Patient #1 had pain at a level of 8 and dilaudid was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/12/14 at 1:38 AM, Patient #1 had pain at a level of 8 and dilaudid was administered. At 4:09 PM, Patient #1 had pain at a level of 8 and lortab was administered. At 8:46 PM, Patient #1 had pain at a level of 8 and dilaudid was administered.
There was no documentation to identify the location, quality, onset or duration of the patient's pain.

3. Medical record review revealed Patient #4 was admitted to the hospital on 4/7/14 with the diagnoses of Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Respiratory Failure, Obstructive Sleep Apnea, Hypertension, Atrial Fibrillation, Hypothyroid, Gastric Esophageal Reflux, Obesity, Diabetes, Lethargy, Shortness of Breath and Weakness.
Record review revealed the patient's pain was rated on a 0 to 10 pain scale, with 10 being the worst pain, and included the following:

On 5/7/14 at 2:24 AM 2 Hydrocodone tablets were administered. There was no pain assessment or indication documented for the administration of the Hydrocodone.
At 5:09 PM and 8:23 PM the patient had a pain level of 6 and 1 Hydrocodone tablet was administered each time. There was no pain assessment to identify the location, quality, onset or duration documented for the patient's pain.

On 5/8/14 at 3:26 PM the patient was administered 2 Hydrocodone tablets. There was no documentation the patient's pain was assessed.
At 8:01 PM 2 Hydrocodone tablets were administered. There was no documentation the patient's pain was assessed.
At 8:26 PM the patient had pain at a level of 8. There was no pain assessment to identify the location, quality, onset or duration documented for the patient's pain.

On 5/9/14 at 5:38 AM the patient was administered 2 Hydrocodone tablets. There was no documentation the patient's pain was assessed.
At 4:38 PM the patient had a pain level of 8. At 7:36 PM the patient had pain at a level of 7 and 2 Hydrocodone tablets were administered. There was no pain assessment to identify the location, quality, onset or duration documented for the patient's pain.

On 5/10/11 at 8:35 AM the patient had pain at a level of 10 and 2 Hydrocodone tablets were administered. There was no pain assessment to identify the location, quality, onset or duration documented for the patient's pain.

On 5/11/12 at 9:55 AM the patient had severe pain at a level of 10 and 2 Hydrocodone tablets were administered. There was no location, quality, onset or duration documented for the patient's pain.
On 5/11/12 at 8:26 PM the patient had pain at a level of 5. There was no interventions, location, quality, onset or duration documented for the patient's pain. At 9:02 PM the patient had severe pain at a level of 10 and 2 Hydrocodone tablets were administered. At 9:21 PM the patient's pain was documented to be a level 4. There was no pain assessment to identify the location, quality, onset or duration documented for the patient's pain.

On 5/12/14 at 4:00 AM the patient had severe pain documented to be a level of 10. At 4:30 AM 2 Hydrocodone tablets were administered for pain and the pain was still documented to be a level 10. There was no location, quality, onset or duration documented for the patient's pain. There was no documentation the pain medication effectiveness was reassessed until 8:00 AM, 3 and 1/2 hours later.

During a tour of the facility on 5/12/14 beginning at 10:25 AM observations revealed Patient #4 up in a recliner chair and had a tracheostomy. The patient was able to communicate by mouthing words. In an interview the patient mouthed they had "back pain" and the medications did "not always" relieve the pain.

4. Medical record review revealed Patient #6 was admitted 4/10/14 with Respiratory Failure, Chronic Obstructive Pulmonary Disease, Paraplegia following Spinal Cord Injury, and Heart Failure.

Record review revealed the patient's pain was rated on a 0 to 10 scale, with 10 being the worst pain, and included the following:

On 5/7/14 at 3:02 AM, he had pain at a level of 7 and oxycontin was administered. At 11:37 PM, he had pain at a level of 7 and oxycontin was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/8/14 at 11:37 PM, he had pain at a level of 8 and oxycontin was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/10/14 at 4:13 PM, he had pain at a level of 5 and oxycontin was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

On 5/12/14 at 4:56 PM, Patient #6 had pain at a level of 5 and oxycontin was administered. There was no documentation to identify the location, quality, onset or duration of the patient's pain.

Based on policy review and observation, it was determined the facility failed to ensure all employees performed appropriate hand hygiene for 1 of 2 (Registered Nurse (RN) #1) RNs observed.

The findings included:

1. Review of the facility, Hand Hygiene And Surgical Hand Antisepsis Policy revealed, "Purpose: to delineate expectations regarding hand hygiene for all employees to reduce the potential risk of transmission of infection to patients and healthcare workers. Policy... Perform appropriate hand hygiene... after contact with body fluids or excretions, mucous membranes, non intact skin, and wound dressings (example: blood, urine, feces, mouth, draining wounds)... if moving from a contaminated body site to a clean body site during patient care... after contact with inanimate object (example bed rails, bed tables, medical equipment) in the immediate vicinity of the patient... Glove Use... wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur... Change gloves during patient care if moving from a contaminated body site to a clean body site..."

2. Observations on 5/14/14 at 9:55 AM revealed RN #1 prepared and administered medications to Random Patient #1. RN #1 used hand gel, donned gloves, instilled saline and administered an intravenous (IV) antibiotic via the patient's Peripherally Inserted Central Catheter (PICC) line. RN #1 did not remove the contaminated gloves or perform hand hygiene before preparing the patient's oral medications. RN #1 opened the patient's medication packages, held the pills in their hand, still wearing the contaminated gloves and placed them in a souffle medication cup. RN #1 then administered them to the patient.