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Based on review of the hospital's policies and procedures, grievance log and interviews with hospital staff, the hospital failed to follow its grievance process. This occurred in one of three (#2) grievances reviewed.

Findings:

In a telephone interview with Patient #2 representative, the representative stated she spoke with the hospital's grievance coordinator (identified by name) and the Chief Nursing officer (identified by name) regarding the treatment of Patient #2.

Review of the hospitals grievance log for the year 2015 did not contain documentation an investigation or written response, with the required information, had been sent to the complainant.

On 06/01/2015 at 10:20 a.m. the grievance coordinator told the surveyors he had not received any complaints or grievances from Patient #2 or anyone on behalf of the patient.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure restraints were applied in accordance with physician orders. This occurred in two of three (# 4, #7) patients in restraints.

Findings:

A hospital protocol/procedure, with the subject, "Use Of Restraints", documented, "...a restraint may be released early. However, if the same behavior becomes evident again, a new order must be obtained. Documentation for a patient in a restraint device will include but is not limited to: a. Clinical Justification for the use of restraints..."

A tour of the hospital was conducted on 05/29/2015 at 8:55 a.m. with the Chief Nursing Officer (CNO). Current patients' medical records were reviewed with the CNO at the conclusion of the tour.

The CNO was interviewed on 05/29/2015 at 10:05 a.m., the CNO stated staff are taught to get a new order when a patient is placed back in restraints.

Review of medical record for Patient #4 contained incomplete restraint orders. Restraint orders dated for 05/17/2015 and 05/18/2015 did not contain the clinical justification for use and the criteria for discontinuing the restraints.

Patient # 4 restraints were removed on 05/17/2015 at 4:00 p.m.. The restraints were re-applied on 05/18/2015 at 8:00 a.m. without a new physician order for the re-application of the restraints. This was confirmed by the CNO during medical record review on 05/29/2015.

Review of Patient #7 medical record contained incomplete restraint orders. Restraints orders dated for 04/06/2015, 04/07/2015, 04/17/2015 and 04/22/2015 did not contain the clinical justification for use and the criteria for discontinuing the restraints. This information was presented to the Staff J on the afternoon of 06/01/2015. The missing information was corrected during the survey.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure a registered nurse (RN) assigned, supervised and evaluated the nursing care for six of six (Patients #9, 10, 11, 12, 13, 14, 15) current patients and two of three (Record #1, #2) discharged patient whose records were reviewed for nursing care.

Findings:

The hospital's assessment policy, which complied with the nursing standard of practice, required a RN to complete the initial assessment and to reassess the patient at least every day. The policy required complete physical assessments to be completed at least every twelve-hour shift on each patient.

1. The supervising RN did not assure a RN performed a physical assessment every day on each patient. Records #1, 10, 12, 13 and 15 did not contain evidence a RN assessed the patient every day.

~ Record #1 - a RN did not assess the patient's physical condition on 02/09/2015, 02/12/2015, 02/13/2015, 02/15/2015, 02/25/2015, 02/24/2015 and 02/23/2015.

~ Records #10, 13 and 15 - a RN did not assess the patient's physical condition on 05/22/2015, 05/23/2015 and 05/24/2015.

~ Record #12 - a RN did not assess the patient's physical condition on 05/23/2015 and 05/24/2015.


2. The supervising RN did not ensure nursing assessment and documents were completed each shift, every day for each patient.

~ Records #9, 10, 12, 14 and 15 did not contain nursing documentation, including assessments, for 05/21/2015.

~ Record #9 did not contain nursing documentation, including assessments, for 05/22/2015.

~ Staff K stated on 06/01/2015 at 1:53 p.m. that nursing documents for Records #9, 10, 12, 14 and 15 were not in the medical records and could not be located.


3. The supervising RN did not evaluate the care provided by agency nursing staff to ensure medications and nursing care were provided.

~ Record #2 - Agency staff did not administer medications as ordered. See Tag A-0405 for details.

~ Record #9 - Agency staff did not perform and/or document nursing assessments. See Tag A-0398 for details.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure four of four (Staff Q, R, S, T) non-employee (agency) nursing staff, whose personnel files were reviewed, were:

a. orientated to hospital policies and procedures;
b. evaluated to assure the staff had the skills and competency to the meet the specialized needs of the hospital's patients; and
c. supervised to ensure hospital policies and procedures were followed and patient care activities were completed.

Findings:

On 05/29/2015 at 9:45 a.m., Staff K told the surveyors that hospital nursing staff worked 12-hour shifts - 7:00 a.m. until 7:00 p.m. (day) and 7:00 p.m. until 7:00 a.m. (night).

1. Medical record #9 contained documentation that four agency nursing staff were assigned and provided care to the patient between the dates of 05/18/2015 and 05/24/2015.

The hospital's policy on patient assessments required complete physical assessments to be completed at least every shift.

~ The record did not contain a nursing assessment by agency Staff Q on 05/18/2015, night shift.

~ The nursing assessment on 05/19/2015, night shift, did not contain a signature of the staff who performed the patient assessment. Agency Staff S documented the nursing narrative notes for the night shift on 05/19/2015. The nursing patient care assignment form recorded agency Staff S was assigned to Patient #9 on 05/19/2015.

~ The record did not contain a nursing assessment on 05/20/2015, night shift. Nursing patient care assignment documents recorded agency Staff T was assigned to Patient #9 on 05/20/2015.

2. The personnel files for agency Staff Q, R, S, and T did not contain evidence the nurses had been orientated to the hospital's policies and procedures and protocols.

~ On 05/26/2015 at 11:55 a.m., Staff U told the surveyors that the house supervisor and the nursing educator were responsible for all the orientation of agency staff. Staff U stated the agency nurses were given a packet to complete and return, upon arrival for their first shift.

~ The agency orientation packet did not contain evidence of orientation to hospital policies and procedures.

3. The personnel files for agency Staff Q, R, S, and T did not contain evidence of skills and competency verification and evaluation.

~ On 05/26/2015 at 12:10 p.m., Staff U stated the hospital trusted the agency to verify and evaluate the nursing staff they sent.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure medications were administered in accordance with physician orders. This occurred in one (#2) of three discharged patient whose records were reviewed for medication administration.

Findings:

Review of a hospital policy and procedure, titled, "Administration, Time of Medication", documented, "...QID [ four times a day] 0900-1300-1700-2100..."

On 06/02/2015 at 2:30 p.m., the Chief Nursing Officer (CNO) stated medications may be administered one hour prior to and one hour after the scheduled time.

Patient #2 - The physician ordered oral Oxy-IR 15 milligram(mg) - 30 mg every six hours as needed for pain. The physician order changed on 04/23/2015 to oral Percocet 10 mg to be administered QID. The physician order written on 04/24/2015 discontinued the Percocet and the Oxy-IR.

Review of the medical record for Patient #2 contained the following administration time for Oxy-IR and Percocet:

~04/12/2015 and 04/17/2015- No documentation of either medications administered to the patient.

~04/24/2015- The nurse documented Percocet administered at "0900", "1300" and "1700."

The medication report from the hospital's "Med Dispense" system was reviewed on the afternoon of 06/02/2015 with the CNO.

The report documented agency nurses removed Oxy-IR and Percocet from the Med-Dispense system for Patient #2 as follows:

~04/12/2015- Oxy-IR 30 mg at "23:58".

~04/17/2015- Oxy-IR 30 mg at "13:14".

~ 04/24/2015- Percocet 10 mg at "10:40" and "15:04".

Review of the Quality Assessment and Improvement Performance (QAPI) meeting minutes for the year 2015 contained documentation the hospital and pharmacist were aware and monitored the number of medication errors committed by agency nurses. This was confirmed by CNO on the afternoon of 06/02/2015 during review of the mediation report.