HospitalInspections.org

Based on policy and procedure review and staff interview, the hospital staff failed to identify and respond to a grievance for 1 of 1 complaints reviewed (Patient #1).

The findings include:

Review of policy titled "Patient/Family Complaint and/or Grievances", last reviewed/revised 04/2017, revealed "...Purpose To provide a mechanism for patients and their families to make complaints regarding patient treatment and care and by which prompt resolution of problems can be accomplished. Policy The governing body is responsible for managing the grievance process and has delegated responsibility to the QAPI (Quality Assessment Performance Improvement) Committee/QC Council to investigate and resolve patient grievance. Patient or family members may make a complaint by addressing their concerns verbally or in writing to any member of the hospital team. Procedure ....2. The individual receiving the complaint will initiate the Complaint /Grievance Form and take any steps available to resolve the complaint. After documenting efforts to resolve the complaint, the Complaint/Grievance Form should immediately be given to the appropriate Department Head....The patient/family will be kept informed of all efforts made to resolve their complaint....Once the Quality Manager makes a final decision a written response will be provided the complaint within 7 days of the complaint being received. ..." Policy review failed to reveal a definition of a grievance.

Requests for a complaint or grievance file revealed there was no grievance file for Patient #1.

Interview with Case Manager (CM) #1, on 04/18/2018 at 1545, revealed Patient #1's family member made CM #1 aware the patient had a wound. Interview revealed the family member was "pretty upset" about it. CM #1 stated the family member also came forward with a concern that a staff member did not maintain the patient's privacy. Interview revealed CM #1 did not recall if she carried the concerns forward. Interview revealed CM #1 did not consider the concerns a complaint or grievance, just considered that the family member was concerned about the patient.

Interview with Administrative Staff (AS) #3, on 04/18/2018 at 1410, revealed AS #3 became aware of the complaint at this hospital (Hospital A) after the patient was transferred out. Interview revealed the patient required transfer to another hospital (Hospital B) and afterwards was subsequently transferred to Hospital C (a sister facility to Hospital A) because the family member did not want Patient #1 to return to Hospital A. Interview revealed the family member thought Hospital A caused a wound and was unhappy with wound care. Interview revealed AS #3 spoke with the family member while Patient #1 was at Hospital C. AS #3 stated the focus was on ensuring the care at Hospital C met the patient's/family member's needs. Interview revealed the concern expressed about care at this hospital (Hospital A) was not considered a grievance and no follow up letter was sent.

Based on policy and procedure review, medical record review, event report review and staff interviews facility staff failed to provide wound treatments per orders for 1 of 4 patients with wounds (Patient #1), and failed to turn and reposition a patient every two hours per orders for 3 of 4 patients with wounds (Patient #1, #8, and #4).

The findings include:

1a. Review of a policy on 04/17/2018 titled "Pressure Ulcer Plan of Care" last reviewed 04/2015 revealed "...A wound treatment plan will be initiated for a patient at time of admission or upon development of a wound...Timely and appropriate management of wounds can decrease patients' morbidity and mortality and increase comfort and general quality of life...2. Principles of wound care D. Cleanse wound initially and at each dressing change..."

Closed medical record review on 04/18/2018 of Patient #1's medical record revealed a 63 year old male admitted on 10/24/2017 for "supportive care for stroke, respiratory care and rehabilitation." Review of RN #1's (Registered Nurse) initial wound assessment and treatment plan on 10/24/2017 revealed "...the patient presents with erythema and deep tissue injury that is noted to the buttocks area, but there are no open areas noted, so today this area was cleansed with soap and water, and a foam dressing was applied. We will recommend for future treatments that this area be treated with Vitamin A&D ointment every shift..." Review of the treatment orders started on 10/24/2017 for the wound revealed "...Buttocks Clean with peri wash apply vitamin A & D ointment q shift..." Review of the nursing wound assessment flowsheet from 10/25/2017 to 11/06/2017 revealed no available documentation of buttocks wound care on: 10/25/2017 7pm-7am shift, on 10/26/2017, on 10/27/2017 7am-7pm shift, on 10/28/2017, on 10/29/2017, on 10/30/2017 7pm to 7am shift, on 11/01/2017 7am-7pm shift, on 11/02/2017 7am-7pm shift, and on 11/03/2017 7am-7pm shift. Review of the nursing note on 11/04/2017 at 1220 revealed "...late entry-note left for WOC (wound care nurse) regarding buttock wound to be reassessed..." Review revealed RN #1 came to assess Patient #1's wound again on 11/06/2017. Review of the "WOUND CARE PROGRESS NOTE" dated 011/06/2017 revealed "...The patient was seen today by Wound Care for a weekly evaluation...the patient...has a coccyx buttocks unstageable wound that measures 10 x 10 x 0.1..." Further review revealed new treatment orders were placed for Patient #1's wounds. Review of the nursing wound assessment flowsheet from 11/07/2018 to 11/14/2018 revealed no available documentation of buttocks wound care on 11/08/2017 7am-7pm shift. Review revealed Patient #1 was discharged to a rehabilitation facility on 11/14/2017.

Review on 04/18/2018 of an "EVENT REPORT" dated 11/06/2017 revealed "Pt previously noted with non blanchable erythema & DTI (deep tissue injury). Now has worsening erythema, DTI & non viable tissue. Current recommendation for honey gel & non adherent dsg (dressing) Q shift with pulse lavage (irrigating a wound with a pressurized solution) 3x/week (three times per week). Further review of the supervisor investigation revealed "Pt admitted with DTI was at high risk for further breakdown noted all dsg (changes) not documented on tx (treatment) sheet education provided to nurses..."

Interview on 04/18/2018 with AS #1 (Administrative Staff) revealed she investigated Patient #1's event report dated 11/06/2017. Interview revealed AS #1 reviewed Patient #1's medical record including nursing notes and treatment orders. Interview revealed AS #1 found Patient #1's wound treatments were not being consistently documented. Interview revealed she provided one on one education to the nurses with inconsistent documentation including RN #2. Interview revealed the expectation was that wound treatments would be documented on the wound assessment record.

Interview on 04/18/2018 at 1445 with RN #2 revealed wound care was done based on what was on the patient's wound treatment sheet. Interview revealed if wound care was done on a patient it should be documented on the wound assessment. Interview confirmed that Patient #1 did not have wound care documented consistently. Interview revealed RN #2 had been educated by AS #1.

Interview on 04/19/2018 at 1035 with RN #1 revealed from the initial assessment of Patient #1's wound to the second time she saw Patient #1 the wound had worsened. Interview revealed RN #1 filled out an event report because Patient #1's wound had worsened.

1b. Review of a policy on 04/17/2018 titled "Pressure Ulcer Plan of Care" last reviewed 04/2015 revealed "...Timely and appropriate management of wounds can decrease patients' morbidity and mortality and increase comfort and general quality of life..Turn every two hours according to established facility routine...Decrease friction and shear forces through proper positioning, transfer and turning techniques using a draw sheet..."

Closed medical record review on 04/18/2018 of Patient #1's medical record revealed a 63 year old male admitted on 10/24/2017 for "supportive care for stroke, respiratory care and rehabilitation." Review of the treatment orders started on 10/24/2017 for the wound revealed "...Turn pt (patient) q (every) 2 hrs (hours)..." Review of the "DAILY INTAKE/OUTPUT WORKSHEET" revealed Patient #1 was not turned or repositioned during the following dates and times: on 10/26-27/2017 from 2130 to 0330, on 10/30/2017 from 1450 to 1940 and from 0340 to 0820, on 11/03/2017 from 1900 to 2200, on 11/04/2017 from 1800 to 2100, on 11/06/2017 from 1600 to 1910, on 11/08/2017 from 1700 to 2110, on 11/09/2017 from 1700 to 2020, on 11/11/2017 from 1430 to 1900, on 11/12/2017 from 0402 to 0830 and from 0830 to 1400 and from 1400 to 1715 and from 1715 to 2000, and on 11/13/2017 from 1200 to 2000. Review revealed Patient #1 was discharged on 11/14/2017 to a rehabilitation facility.

Interview on 04/18/2018 with AS #1 revealed patient's should be repositioned every two to three hours. Interview revealed the expectation was for repositioning orders to be followed.

Interview on 04/19/2018 at 0845 with CNA #1 (Certified Nursing Assistant) revealed patients should be turned every two hours no more than three hours. Interview revealed that if a patient refused to turn then it would be documented on the intake/output worksheet.

Interview on 04/17/2018 with RN #1 revealed she saw Patient #1 on 10/24/2017, 11/06/2017, and 11/13/2017 to assess his wound. Interview revealed between 10/24/2017 and 11/06/2017 Patient #1's wound had gotten worse. Interview revealed Patient #1 orders were to turn every two hours.






39307

2. Review of an open medical record on 04/18/2018 of Patient #4 revealed, an 85 year old African American female was admitted on 02/28/2018, following Laparoscopic Cholecystectomy on 01/15/2018 and subsequent bile duct injury. Review revealed a consult order on 02/28/2018 to turn patient every two hours. Review of the "DAILY INTAKE/OUTPUT WORKSHEET" REVEALED Patient #4 was not turned or repositioned during the following dates and times:
Date Time
- 04/02/2018 At 1600 - 1800 Back position documented, NO further documentation of position until 04/03 at 0800 (for 14 hours later)

- 04/07/2018 At 1600 - 2015 Back position documented (>4 hours), then at 2015 - 2430 Left position documented (>4 hours)

- 04/08/2018 At 1600 - Back position documented, then at 2030 as Right position documented (4 hours 30 minutes later) at 2430 - 0430 Back position documented (for 4 hours)

- 04/10/2018 At 2000 - arrows down as "rotation therapy via bed" (12 hours)

- 04/12/2018 At 0800 - 1200 Right position documented (4 hours) at 1200 - 1500 Chair position documented (3 hours)

- 04/14/2018 At 1215 - Left position documented, the next documentation is at 2000 - Right position documented (8 hours)

- 04/16/2018 At 0800 - 1300 Back position documented (for 5 hours)

- 04/17/2018 At 1610 - 2000 Left position documented (4 hours)

Interview during tour of facility on 04/17/2018 at 1405 with RN#6 revealed turning and repositioning every 2 hours is the expectation of nursing staff as per policy.

Interview on 04/18/2018 at 1230 with AS #1 revealed "it is my expectation to have the documentation reveal exactly what position the patient is in on the document." Interview with AS #1 confirmed the record failed to reveal position changes to prevent pressure as documented above for Patient #4. Regarding Patient #4 AS #1 stated, "therapy via bed documented on 4/10/2018 at 2000 is not acceptable documentation." The interview with AS #1 revealed the patient was not turned according to policy.

3. Review of an open medical record on 04/18/2018 of Patient #8 revealed a 70 year old morbidly obese Caucasian male admitted on 04/09/2018 for weakness and a large infected stage 4 sacral decubitus ulcer needing IV antibiotics. Medical record review revealed multiple co-morbidities, including epidural abscess with discitis and osteomyelitis, surgeries of bilateral knee replacements, and rapid atrial fibrillation recently. Reveiw of a wound care progress note on 04/10/2018 revealed "... Plan 1. Decubitus ulcer of sacral region, stage 4 ...Offloading Turning, positioning Limit sitting to 2 hours .... " Review of the "DAILY INTAKE/OUTPUT WORKSHEET" REVEALED Patient #8 was not turned or repositioned during the following dates and times:
Date Time
- 04/09/2018 After 0000 there is NO documentation of position change until 04/10/2018 at 0800 (8 hours)

- 04/13/2018 At 1449 - 2130 documented as Left position (>7 hours)

Interview during tour of facility on 04/17/2018 at 1405 with RN#6 revealed turning and repositioning every 2 hours is the expectation of nursing staff as per policy.

Interview on 04/18/2018 at 1130 with RN #7 revealed, "Patients are suppose to be turned and repositioned every 2 hours."

Interview on 04/18/2018 at 1230 with AS #1 revealed "it is my expectation to have the documentation reveal exactly what position the patient is in on the document." Interview revealed the staff did not follow policy as the facility expected.

NC00136185