Medical City Fort Worth

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to provide in writing its resolution of the complaint/grievance for 1 of 2 patients (Patient #2) who filed a complaint to the hospital on [DATE].

Findings included:

Personnel #2 received Patient #2's complaint on 9/16/15 via email notification.

In an interview on 11/5/15 at 9:50 AM, Personnel #2 confirmed that a response letter to the above complaint was not sent.

Policy # ADMIN06 revised 1/2013 required In resolution of the grievance, a written notice of the decision must be provided to the complainant...

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital's registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 1 patient (Patient #2) who presented in the emergency department (ED) on 9/15/15. The nursing staff did not offer toileting opportunities to Patient #2 who was [AGE] years old and had history of dementia.

Findings included:

Patient #2 presented in the ED on 9/15/15 at 9:21 AM with a chief complaint of falling from a chair. The patient was discharged at 9:21 PM with a diagnosis of fall without injury. From the time the patient presented in the ED and to the time he was discharged (12 hours), there was no documentation that the patient was offered toileting opportunities and/or if his disposable brief was changed.

In an interview on 11/5/15 at 9:50 AM, Personnel #2 confirmed the above findings.

Policy #ED71 ED Standards for Documentation...and Reassessments revised 1/2014 required B. Documentation of reassessment...should reflect...any interventions performed...F. reassessments should occur...or done at a minimum...every 4 hours or more...

Based on record reviews and interviews, the hospital failed to protect and promote patient rights for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

Cross Reference to Tag A-0144

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to provide care in a safe setting for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

FINDINGS INCLUDED

1) Turns:

The 7/07/14 through 7/15/14 turn documentation for Patient #13 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings and stated, the patients are to be turned every two hours and it should be documented.

The 6/09/14 through 6/17/14 turn documentation for Patient #14 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient#14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

The 12/09/13 through the 1/27/14 turn documentation for Patient #15 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

2) Photographs:

Patient #13 was hospitalized from [DATE] through 7/15/14. There was one photograph of Patient #13's wound on 7/07/14. The wound documentation indicated, 7/07/14...Right Buttock...Yellow slough...Full thickness...Blanchable...Size (cm) (L x W): 5 X 4... There were no photographs to document the wound for 7/14/14 or prior to discharge on 7/15/14.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings.

Patient #14 was hospitalized from [DATE] through 6/17/14. There were no photographs to document the wound on admission. There was one photograph of Patient #14's wound taken on 6/10/14. The wound documentation indicated the buttocks (they were circled) and noted, Stage IV...Size (cm) (L x W): 6 x 6 Depth (cm): 2 Tunneling (cm): 1cm Undermining (cm): 1 cm... There were no photographs to document the wound prior to discharge on 6/17/14.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

Patient #15 was hospitalized from [DATE] through 3/12/14. There was no wound on admission. The wound developed during the stay. On 12/18/13 at 8:00 PM, the nurse note stated wound present. There was no photograph to document the wound upon discovery. There were photographs to document the wound on 12/27/13, 1/09/14, 2/10/14 and 2/12/14. The wound documentation indicated, sacrum/coccyx/left buttock...12/27/13 (picture date)...opaque (intact fluid filled blister)...purple/maroon/deep hues of red (or blood filled blister)...Stage II, Blister...non-blanchable...Size (cm) (L x W): 8 x 8... The wound documentation indicated, Sacrum...1/09/14...purple/maroon/deep hues of red (or blood filled blister)...unstageable...partial thickness...non-intact...(no measurements included)... The wound documentation indicated, Sacrum...2/06/14...Yellow (slough)...unstageable...Boggy...non-intact...(no measurements included)...Exudate: Serosanguineous... The wound documentation indicated, Sacrum...2/10/14 (picture date)Yellow (slough)...unstageable...Boggy...non-intact...bumpy...non-blanchable......(no measurements included)...Serosanguineous...Purulent...moderate... The wound documentation indicated, Sacrum...2/12/14 (picture date)...Exposed Muscle/Tendon/Bone...Stage IV...Non-intact...Non-blanchable...Size (cm) (L x W): 11.0 x 10.0...Depth (cm): 5.0 cm Undermining (cm): 4 cm...

There was no photograph to document the wound weekly. There were no photographs for 1/03/14, 1/17/14, 1/24/14, 1/31/14, 2/21/14, 2/28/14, 3/07/14, or 3/12/14 prior to discharge.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #16 was asked about the hospital's policy in regard to completing the assessment within 24 hours, photographing the wound weekly until healed. Personnel #16 said she knew the policy and the nurses complete the wound care and photographs. Personnel #16 said, no. The wounds were not photographed weekly by staff.

3) Admission Assessment:

The 6/09/14 at 5:40 PM Nurse Admission Assessment for Patient #14 stated, Pressure ulcer #2 location: Lt (left) Heal...Comment: Unseen at this time... The dressing was not removed and the wound was not assessed upon admission.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings and said, the nurse should have undressed the wound and assessed it.

4) Wound Care Consult:

The 6/09/14 History and Physical for Patient #14 stated, ...wound care consult will be obtained.

Patient #14's wound care consult assessment was not completed within 24 hours of the consult.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

5) Meals:

There was no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

The 07/2012 Patient's Rights and Responsibilities policy required, affirm a basic operating philosophy that the observance of certain patients' rights and responsibilities will contribute to more effective patient care and greater satisfaction of the patient...The patient has the right to considerate care...recognition of personal dignity...

Based on record reviews and interviews, the hospital failed to have an organized nursing service that provided nursing care for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

Cross Reference to Tag A-0395

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record reviews, the hospital failed to ensure Registered Nurses (RN's) evaluated, prevented, and provided treatment for 3 of 3 patients (Patient #13, #14, and #15) who had altered skin integrity identified during the admission, in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

FINDINGS INCLUDED

1) Turns:

The 7/07/14 through 7/15/14 turn documentation for Patient #13 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings and stated, the patients are to be turned every two hours and it should be documented.

The 6/09/14 through 6/17/14 turn documentation for Patient #14 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

The 12/09/13 through the 1/27/14 turn documentation for Patient #15 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

2) Photographs:

Patient #13 was hospitalized from [DATE] through 7/15/14. There was one photograph of Patient #13's wound on 7/07/14. The wound documentation indicated, 7/07/14...Right Buttock...Yellow slough...Full thickness...Blanchable...Size (cm) (L x W): 5 X 4... There were no photographs to document the wound for 7/14/14 or prior to discharge on 7/15/14.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings.

Patient #14 was hospitalized from [DATE] through 6/17/14. There were no photographs to document the wound on admission. There was one photograph of Patient #14's wound taken on 6/10/14. The wound documentation indicated the buttocks (they were circled) and noted, Stage IV...Size (cm) (L x W): 6 x 6 Depth (cm): 2 Tunneling (cm): 1cm Undermining (cm): 1 cm... There were no photographs to document the wound prior to discharge on 6/17/14.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

Patient #15 was hospitalized from [DATE] through 3/12/14. There was no wound on admission. The wound developed during the stay. On 12/18/13 at 8:00 PM, the nurse note stated wound present. There were no photographs to document the wound upon discovery. There were photographs to document the wound on 12/27/13, 1/09/14, 2/10/14 and 2/12/14. The wound documentation indicated, sacrum/coccyx/left buttock...12/27/13 (picture date)...opaque (intact fluid filled blister)...purple/maroon/deep hues of red (or blood filled blister)...Stage II, Blister...non-blanchable...Size (cm) (L x W): 8 x 8... The wound documentation indicated, Sacrum...1/09/14...purple/maroon/deep hues of red (or blood filled blister)...unstageable...partial thickness...non-intact...(no measurements included)... The wound documentation indicated, Sacrum...2/06/14...Yellow (slough)...unstageable...Boggy...non-intact...(no measurements included)...Exudate: Serosanguineous... The wound documentation indicated, Sacrum...2/10/14 (picture date)Yellow (slough)...unstageable...Boggy...non-intact...bumpy...non-blanchable......(no measurements included)...Serosanguineous...Purulent...moderate... The wound documentation indicated, Sacrum...2/12/14 (picture date)...Exposed Muscle/Tendon/Bone...Stage IV...Non-intact...Non-blanchable...Size (cm) (L x W): 11.0 x 10.0...Depth (cm): 5.0 cm Undermining (cm): 4 cm...

There were no photographs to document the wound weekly. There were no photographs for 1/03/14, 1/17/14, 1/24/14, 1/31/14, 2/21/14, 2/28/14, 3/07/14, or 3/12/14 prior to discharge.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #16 was asked about the hospital's policy in regard to completing the assessment within 24 hours, photographing the wound weekly until healed. Personnel #16 said she knew the policy and the nurses complete the wound care and photographs. Personnel #16 said, no. The wounds were not photographed weekly by staff.

3) Admission Assessment:

The 6/09/14 at 5:40 PM Nurse Admission Assessment for Patient #14 stated, Pressure ulcer #2 location: Lt (left) Heal...Comment: Unseen at this time... The dressing was not removed and the wound was not assessed upon admission.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings and said, the nurse should have undressed the wound and assessed it.

4) Wound Care Consult:

The 6/09/14 History and Physical for Patient #14 stated, ...wound care consult will be obtained.

Patient #14's wound care consult assessment was not completed within 24 hours of the consult.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

5) Meals:

There was no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #17 was asked about the findings of no documentation of the patient receiving meals, supplements and/or tube feedings from 12/09/13 through 12/16/13 at 8:00 PM. Personnel #17 said the patient was ordered a Cardiac diet on 12/09/13 and trays go to the patient as ordered. Personnel #17 said the nursing staff were to document the meal consumption. Personnel #17 said when she evaluated Patient #15, she saw that the nurses had not documented meals received/consumed. When asked if she had made note of this in Patient #15's record, Personnel #17 said, no.

The 06/2013 Assessment, Prevention, Treatment, and Photographing of Skin Breakdown, and Notification of Enterstomal Therapy policy required, ...assess the skin integrity on admission, each shift, and with any significant change in the patient's condition...in order to plan appropriate measures for the prevention or the treatment of skin breakdown. The nurse will photograph all existing pressure ulcers and wounds during admission assessment and weekly until healed and any new pressure ulcers or wounds noted during the course of hospitalization ...All dressings should be removed upon initial admission, for assessment including wound VAC (vacuum assisted closure) dressings...The patient can expect maintenance of intact skin while hospitalized ...consultation by the WOCN (Wound, Ostomy and Continence Nurse) will occur within a 24 hour period or one business day after weekends or holidays...

The revised 03/(20)12 Wound Care Protocols required, photograph, measure, stage, and document wounds and pressure ulcers at the time of initial assessment and weekly...reduce pressure over affected areas; turn and support with pillows at least every 2 hours...

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the governing body failed to ensure that a physician was on call at all times in that 1 of 1 patient (Patient #1) did not receive pain medication in a timely manner after Physician #9's answering service was contacted by Nurse #1. On 04/11/11 at 01:25 AM, Nurse #1 requested Physician #9 to return an answering service request for a call back to discuss Patient #1's pain medication. Patient #1 did not receive the pain medication until 05:36 AM (approximately 4 hours after Physician #9 was first contacted).

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, [AGE], was admitted on [DATE] with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The History and Physical unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was screaming out loud...demanding for her pain meds (medications)... At 04:30 AM, Nurse #1 placed another call to the answering service.

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 Medication Discharge Summary indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to Demerol... At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:45 PM on 07/01/11, the Associate Chief Nursing Officer (Personnel #10) was asked if there were guidelines for a physician's response to a request for return contact by a nurse. Personnel #10 said that the Medical Staff had rules regarding this and there were protocols to follow if the physician was not able to be reached.

The Medical Staff Rules and Regulations reviewed by the Medical Executive Committee 04/13/10 and adopted by the Board of Trustees on 04/26/10 included that Each practitioner must assure timely, adequate, professional care for his patients in the hospital by being available or having available through his office an alternate practitioner...

The Chain-of-Command and Administrative Call policy #ADMIN106 revised October 2010, included that, No more than two (2) calls will be made to the physician prior to invoking the Chain-of-Command...

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the hospital failed to provide 1 of 1 patient (Patient #1) care in a safe setting in that Patient #1 did not receive appropriate management of pain. Patient #1 asked for pain medication at 01:25 AM on 04/11/11 and did not receive the medication until approximately 4 hours later, at 05:36 AM. In addition, Physician #9 prescribed a medication that Patient #1's medical record indicated she was allergic to prior to Physician #9 giving an order for the correct pain medication. This practice could have presented the risk of potential harm to Patient #1.

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, [AGE], was admitted on [DATE] with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The History and Physical unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was screaming out loud...demanding for her pain meds (medications)... At 04:30 AM, Nurse #1 placed another call to the answering service.

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 Medication Discharge Summary indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to Demerol... At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:00 PM on 07/01/11, Registered Nurse #4 was asked what she remembered about Patient #1. RN #4 reviewed Patient #1's nursing notes and stated that she remembered that Patient #1 wouldn't listen and was screaming. She had wanted pain medication from her nurse who was contacting the physician.

The hospital's Patient's Rights and Responsibilities policy #ADMIN03, revised August 2009, included that The patient has a right to appropriate assessment and management of pain. The patient can expect information about pain and pain relief measures, and a concerned staff committed to pain management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the hospital failed to have a well-organized nursing service with a plan of administrative authority in that 1 of 1 patient (Patient #1) who requested pain medication on 04/11/11 at 01:25 AM did not receive the medication until 05:36 AM (approximately 4 hours after the first call to the physician's answering service by Nurse #1 and more than 2 subsequent attempts at contacting Patient #1's physician for pain management).

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, [AGE], was admitted on [DATE] with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The History and Physical unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was screaming out loud...demanding for her pain meds (medications)... At 04:30 AM, Nurse #1 placed another call to the answering service.

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 Medication Discharge Summary indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to Demerol... At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:45 PM on 07/01/11, the Associate Chief Nursing Officer (Personnel #10) was asked if there were guidelines for a physician's response to a request for return contact by a nurse. Personnel #10 said that the Medical Staff had rules regarding this and protocols to follow if the physician was not able to be reached.

The Medical Staff Rules and Regulations reviewed by the Medical Executive Committee 04/13/10 and adopted by the Board of Trustees on 04/26/10 included that Each practitioner must assure timely, adequate, professional care for his patients in the hospital by being available or having available through his office an alternate practitioner...

The Chain-of-Command and Administrative Call policy #ADMIN106 revised October 2010, included that, No more than two (2) calls will be made to the physician prior to invoking the Chain-of-Command...