HospitalInspections.org

Based on interview and record review, the hospital failed to provide a letter of response to 1 of 1 (Patient #3) patients filing a complaint in 2016, thereby not adhering to their policy.

Findings Included:

Patient #3 was admitted on 11/19/16 for wound therapy. On 12/30/16, Patient #3 filed a complaint. The hospital did not provide a response letter to Patient #3's complaint.

During an interview on 2/1/17 at 3:45 PM, Personnel #1 was asked for the investigation and response to the complaint. Personnel #1 stated she did not follow the grievance process.

The policy titled Grievance, Patient/Family dated 9/02 and updated 7/16 reflected...The patient/patient representative will be given a written response within 7 calendar days of the grievance notification. If the grievance is still in the process of being resolved on day 7, the patient/patient representative will be provided a written notification that the hospital is in the process of resolving the grievance and the anticipated day of resolution...

Based on record review and interview, the hospital failed to secure an order for restraints from a physician or other licensed independent practitioner who was responsible for the care of the patient in that, 1 of 1 (Patient #7) patients was restrained with bilateral wrist restraints on 12/1/15 and there was no order for restraints in the chart.

Findings Included:

Patient #7 remained in bilateral soft wrist restraints on 12/1/15 and the physician did not write an order to continue the restraints for 12/1/15.

During an interview with Personnel #1 on 2/1/17 at 4:00 PM, Personnel#1 confirmed there was not an order on the chart for restraints for 12/1/15.

Based on record review and interview, the facility's registered nurse (RN) did not supervise and evaluate the nursing care of the patient:

A. In that, 4 of 5 (Patient #3, Patient #4, Patient#5, and Patient #12) patients the RN did not promptly reassess the patient's after administering pain medication.

B. In that, 2 of 5 (Patient #4 and Patient #5) patients did not receive a daily RN assessment.

Findings Included:

A. Patient #3's Pain Assessment reflected on 11/27/16 at 3:30 PM, Patient #3 complained of pain of 7/10 on a 1-10 scale and that Patient #3 was medicated for pain. The Pain Assessment does not reflect an evaluation of measures used.

Patient #4's undated Pain Assessment reflected at 1:00 PM Patient #4 complained of pain of 3/10 on a 1-10 scale and that Patient #4 was medicated for pain. The Pain Assessment does not reflect an evaluation of measures used.

Patient #5's Pain Assessment reflected on 10/28/16 at 7:00 PM Patient #5 complained of pain of 4/10 on a 1-10 scale and that Patient #5 was medicated for pain. The Pain Assessment does not reflect an evaluation of measures used.

Patient #12's Pain Assessment reflected on 12/11/15 at 10:00 PM Patient #12 complained of pain of 6/10 on a 1-10 scale and that Patient #12 was medicated for pain. The Pain Assessment does not reflect an evaluation of measures used.

During an interview with Personnel #1 on 2/1/17 at 4:00 PM, Personnel #1 stated the policy for pain reassessment did not contain a time frame for follow, but the expectation is within 2 hours.

B. Patient #4's record did not evidence a RN assessment on 11/19/16 and Patient #5's record did not evidence an RN assessment on 11/29/16.

During an interview on 2/1/17 at 4:10 PM Personnel #1 verified that Patient #4 and #5 did not have RN assessments on the above dates.

Based on interview and observation the chief executive officer, the medical staff, and the director of nursing failed to identify problems and/or address problems identified by the infection control officer or officers. They failed to implement successful corrective action plans in the affected problem areas in that, a Foley Catheter bag was laying on the floor under the bed in room 107, multiple patient rooms had used tissues on the floor, and paper towels and bits of paper were found on the floor in the second floor hallway by a hand washing sink.

Findings Included:

During a tour of the hospital on 2/1/17 at 9:45 AM with Personnel #2 the surveyor observed the Foley catheter bag laying on the floor under the bed in room 107. Multiple patient rooms had used tissue and bits of paper on the floors. In the second floor hallway a paper towel and multiple bits of paper were on the floor by the hand washing sink.

During the tour of the hospital on 2/1/17 at 9:45 AM Personnel #2 was informed of the above findings. Personnel #2 was asked if the facility had house keeping staff on duty during the night. Personnel #2 stated they have someone from house keeping on until 11:00 PM. Personnel #2 stated that occasionally they have to remind the night shift staff to help keep the facility picked up.

Centers for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009 stated...III. Proper Techniques for Maintenance...B...2...Do not rest the bag on the floor...