HospitalInspections.org

Based on interview and record review the facility failed to implement a system to clearly explain procedure for the submission of a patient's writtten or verbal grievance/complaint log as evidenced by one of five (Patient's ID #1) complaint and no evidence of a complaint log for greater than 6 months

Findings include:

No complaint log had been kept by the facility for greater than 6 months, and Patient ID#1's complaint could not be discovered or provide evidence of resolution or investigaton of the complaint.

Interview on 4/4/18 at 12:30 pm with Corporate Quality Improvement Director ID#55 reported that she had discovered on 4/3/18 that the facility had not been maintaining a complaint log and therefore no record of tracking the events for greater than 6 months. Asked if that is acceptable, she reported no it is not and it is against policy and regulations.

Interview on 4/4/18 at 1:30 pm with RN#51 reported that yes the patient ID#1 had her room changed from room 125-b, directly across from the construction in the gymnasium to room 104 where she remained untill she left 911 to acute hospital in respiratory distress.

Interview on 4/4/18 at 2:15 pm with Quality Manager ID#53 reported that she has been employed with the facility since Novemberof 2017. Since that time she had not been keeping a log of complaints. She reported that her understanding was that only Grievances are logged in and she began that system in January of 2018.

Record review of facility policy titled, "Patient Concerns, Complaints, Grievances, dated, 12/17 reads:
POLICY
Patients and families have the right to good safe care delivered in a timely manner by an efficient, skilled, and caring staff. Their input is encouraged if there is a perception that such care has not been delivered.
All complaints and grievances are fully investigated and corrective action taken as appropriate with feedback to be provided to the individual initiating the complaint.

Record review of form titled, "Patient Grievance and Complaint Form", revealed Steps that are to be taking when completing the form
STEP 1: Complete Grievance or Complaint
STEP 2: Tracking and Communication
Step 3: Investigation

Based on interview and record review Patient ID#1 care plan revealed no development or implementation of a Care Plan and/or discharge planing by Case Management and or Social Service as evidenced by no documentation in Patient#1's medical record.

Findings include:

On 4/4/18 review of medical record of Patinet ID#1 revealed NO documentatin of an assessment or progress note made by social services/case management in the medical record of Patient ID#1.

Interview on 4/4/18 at 2:30 pm with LVN ID#57 reported that she has been working in Case Management at the hospital for over 5 years. Nurse #57 reported that a patient care plan and discharge starts the minute the patient is admitted to the facility. Is the Case Management department required to document in the patient chart after doing a patient assessment? Yes, we are to document what happened with the patient/family we talked with and complete an assessment of the patient. When asked to show the surveyor in the medical record of patient ID#1; the Case Management assessment or a progress note , Nurse #57 could not find the documentation. She also reported that she did not know the Patient ID#1, but she knows an assessment is required by policy. If a patient or family has a complaint or grievance how is that addressed? Nurse #57 stated," we fill out a report and make sure the Quality person receives it to follow up on it, or if we can handle it in the moment that occurs. Are you too make a report? Yes, we are required to make a report of the occurrence no matter what the outcome.

Record review of policy titled Assessment and Reassessment Social Services and Case Management dated, 12/17 read:
PROCEDURE
... The Social Worker/Case Mangement establishes a treatment plan and goals based on the findings from the initial assessment.
The Social Worker/Case Manager establishes treatment goals and patient/family goals during the evaluation process.
The patient's strengths/needs and personal preferences direct goal formulation.
... Results of patient evaluation/assessment with goals will be documented and placed in medical recors within 24 hour after evaluation.

Based on interview and record review the facility failed to provide a safe setting for Patient ID#1 with a history of Stage 4 Emphysema(chronic respiratory condition). and the family's concern of the affect the setting could have had on patient's condition.

Findings include:

Complaint # Tx 00281398 alleged that Patient ID#1 had been admitted to facility in a room (125-b) directly across from construction site with Stage 4 emphysema and COPD (Chronic Obstructive Pulmonary Disease) contributing to Patient ID#1 chronic respiratory condition worsening due to dust, debris and odor, resulting in Patinet#1 being sent to acute care hospital in respiratory distress..


Observation on 4/4/18 at 09:30 am of the faciities Medical Surgical Unit was clean, uncluttered, staffed appropriately with a census of 28. Room 125-b was found to be directly across from where the construction had been occurring at the time of Patient #1 room assignment upon admission. Room 104, her second room assignment, was observed to be on another hall near the front of the building and close to the open waitng area by the receptionist desk to the hospital.

Interview on 4/4/18 at 10:00 am with RN Charge Nurse ID#52 reported that there had been construction in the facility for over a year. The facility had blocked off the areas with cardboard and plastic tied down with tape to cut down on the dust; but there still was dust. RN # 52 reported that she did not recall the Patient#1 . She did report that when family request a room change they (nurses) try to do that as soon as a room becomes available. Nurse #52 stated, "we get a full report on the patients when admitted including the patient diagnosis and full medical history". She reported she would not place a patient with respiratory diagnosis in a room near the construction because of the dust and debris that could be present.

Interview on 4//4/18 at 10:15 am with RN Director of Medical/Surgical floor, ID#54 that the staff does address room changes as soon as a room becomes available. Yes, during the construction we did have some restraints with room availability, because rooms were blocked by section so, we did not have many private rooms to offer. Asked, if she would place a patient with respiratory diagnosis in a room across from the construction she responded, no. Why? She stated, "chance of high dust could affect a patients breathing".

Interview on 4/418 with RN# 51 at 10:45am agreed during tour of facility that room 125-b was directly across from where the constructin on the gymnasium had taken place. She also reported that sheetrock had been in place, plastic had been applied. When shown the Risk Assessment of the Pre-Construction she agreed that the number one Risk was high for dust.

Interview on 4/4/18 with engineer ID#56 at 2:00 pm reported that a maintenance log is kept of work orders. The work orders contain the repairs that need to be completed. He could not find work order for the rooms 125- and 104 where Patient #1 had ben a patient. Engineer #56, also reported that the construction site was blocked off, sheetrock, and plastic taped to floor, but workers still brought dust out on their boots. Engineer#56 stated," it is hard to contain all the dust and debris in one spot when it comes to construction". Does floor tile remover have odor, "yes". Engineer #56 stated that as the new rooms were completed new air conditioners were put in place. Was room 125-b a new room, No, He reported in the summer, July-August, 2017, the gym was under construction. The newer rooms to get the new air-conditioners were started in the rooms on hall 100, 102, 104 as they were completed.

Record review of Nursing Assignment Sheet revealed that on 7/13/17 & 7/14/17 Patient #1 was in room 125-b directly across from the construction site. Not until 7/15/17 does it show Patient#1 in room 104-b away from the construction site.

Record review of Overall Project Pre-Construction Risk Assessment dated 6/8/2017 completion date 7/25/2017 Pool/Gym revealed the following:
Considerations Expected Impact Actions- Reduce/minimize imp

Air Quality(mold,dust HIGH risk assessment Filtration system will be utilized
temperture, humidity)

Noise HIGH Risk assessment Jack hammer for concrete, floor tile remover from 7:00am-4:00pm