Prisma Health Baptist Parkridge

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 28883 Based on review of grievances, interview, and policy review, the hospital failed to ensure one of three grievances filed by Patient (Pt) #1 had been thoroughly investigated. A review of the medical care provided by the Emergency Department (ED) Provider on 12/18/23 was not completed/documented and the hospital’s written response to the grievance had not been provided timely. The findings included: Review of a Grievance submitted by Pt #1, received by the hospital on 12/21/23; revealed s/he had presented to the ED on 12/18/23. Pt #1 stated s/he made ED staff aware of painful urine and bowel movements, paralysis and severe pain; and had asked them to treat a spinal epidural abscess. The patient stated that doctors would not image or treat this abscess and were denying services that were vital to his/her health. Pt #1 had requested direct information to communicate with the CEO (Chief Executive Officer) of the hospital. Included in the grievance was action documented by the hospital in response to the grievance. The ED Nurse Manager documented a note on 12/21/23 that the patient’s care was reviewed from the 12/18/23 visit. “...S/he was agreeable to discharge and recommendation to follow up with provider as a follow-up from (his/her) ED visit. I do apologize that s/he is not feeling better. (Pt #1) is welcome to return to the Emergency Department at any time for any emergent concerns.” There was no review documented by the Physician Executive or other Provider that could speak to the quality of medical care provided to Pt #1 for the ED visit. A note by Patient Advocate #1 dated 1/25/24 revealed “Called related to (his/her) concerns twice, 1/16 and 1/22 and was unable to reach (Pt #1). Have made Risk aware. Waiting on follow up from the patient.” There was no response noted from Risk after having noted they had been made aware. A letter had been sent by Patient Advocate #1 on 12/28/23 informing Pt #1 that the concerns expressed had been referred to the appropriate individuals and were currently being reviewed; with an anticipated written response on or before 1/20/24. A second letter was sent on 1/21/24 stating the concerns were still currently being reviewed and awaiting responses from proper investigators; with an anticipated written response on or before 2/21/24. A third letter was sent to Pt #1 on 2/21/24 by the Patient Advocate stating an investigation was completed that included a review of the medical record and discussion with the staff involved in the care; apologizing for the lack of sensitivity displayed by the care team. It went on to state that hospital leadership has taken the appropriate actions in following up with your concerns. The hospital’s response had not been timely and the investigation did not include a medical review for the appropriateness of care provided. The grievance was closed on 2/29/24. During an interview on 4/1/26 at 11:48 AM, the Patient Advocacy Manager verified there had been no review documented by a Physician Provider regarding the appropriateness of care provided from a medical standpoint. Review of the policy provided by the hospital entitled “Patient and Family Complaint & Grievance: Prisma Health”, dated 7/21/21 revealed “...Efforts will be made to resolve grievances within seven (7) calendar days. If the grievance review cannot be completed within seven (7) days, the current status will be communicated to the complainant in writing or via verbal communication, stating the reason for the delay and that a resolution letter should be sent within thirty (30) days...All supporting documentation should be documented in the electronic grievance system...”.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 36779 Based on interview, record review and review of Quality Assessment Performance Improvement (QAPI) program documentation, the hospital failed to ensure the quality improvement action plan addressed all contributing factors to the development of pressure wounds when one of four patients reviewed for pressure wounds, Patient 1 (P1) was not repositioned and the skin under the Mepilex (foam type) dressing was not assessed and P1 developed a Stage 3 (full thickness skin loss where the damage extends through the dermis and into the subcutaneous tissue) pressure wound. Findings included: Cross Reference A392 482.23(b) Staffing and Delivery of Care On 07/22/25 at 11:30 AM and 3:31 PM the Quality and Patient Safety Committee Meeting Minutes/Agendas and corresponding Powerpoint presentations dated 10/08/24, 12/10/24, 01/14/25, February 2025 (cancelled and sent as an agenda), 03/11/25, 04/08/25, 05/13/25, 06/10/25, and 07/09/25 were reviewed. Review of the Meeting Minutes dated 03/11/25 revealed, “Pressure injuries is all about accountability with the team turning ...” The corresponding Powerpoint presentation indicated for the Medical-Surgical Unit, “ ...Department Action Plan ...Pressure injury prevention has been ongoing with PST [Patient Service Technician] awareness and accountability.” Review of the Meeting Minutes dated 04/08/25 revealed for the Intensive Care Unit (ICU), “...Action Plan ...Shared RN [Registered Nurse]/PST accountability ... turning during BSSR [bedside shift report] ...” Review of the Meeting Minutes dated 05/13/25, 06/10/25 and 07/09/25 revealed nothing related to prevention of pressure ulcers. On 07/23/25 at 1:30 PM during an observation of the ICU, PST1 was interviewed at 1:46 PM. PST1 stated she does not remember any education or training on pressure ulcer prevention in the past few months. In an interview with RN2 at 1:49 PM, she stated she did not remember any training or education regarding pressure ulcer prevention in the past few months. In an interview with RN3 at 1:57 PM she stated she does not remember any other training or education on prevention of pressure ulcers in the past few months. In an interview with the Site Director (SD) on 07/23/25 at 2:30 PM, the SD confirmed there were no additional QAPI documents to review regarding the hospital’s prevention of pressure ulcers. During concurrent review of the hospital’s Action Plan started 04/01/25 for the prevention of pressure ulcers after P1 developed a Stage 3 pressure ulcer, the SD confirmed the document indicated, “Action Plan ...Activity ...Assessing under mepilex ...Turn and assess at BSSR ...End Date ...ongoing ...” The spaces labeled “Owner” and “Status/Update” were blank. When asked about the end date of “ongoing,” the SD stated, “...Generally that’s what we do.” When asked about the person responsible, she stated the responsible person is the manager of that unit, which in this case is RN1. When asked how they were measuring if the goal was met and the issue was resolved if there were no documented measurable goals, she confirmed there were no documented goals. In an interview with RN1 on 07/23/25 at 2:55 PM, when asked if repositioning dependent patients every two hours was an expectation of the staff she stated, “It’s an expectation.” When asked what has been done to improve patient repositioning and assessment under the Mepilex dressing according to hospital policy and Guidelines, RN1 stated they did one-on-one education with their team members, posted a flyer in the breakrooms and managers “try to do at least 10 audits per week” which she stated were random observation audits. When asked for documented evidence of these interventions, she provided a flyer titled, “2-Person Skin Assessments.” She did not provide any documented evidence of staff education regarding repositioning and assessing under the Mepilex dressing according to hospital policy and Guidelines. In an interview with the SD on 07/23/25 at 3:30 PM, she confirmed there was no documented evidence of staff education regarding repositioning and assessing under the Mepilex dressing according to hospital guidelines and policies.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36779 Based on record review, interviews and review of the hospital’s policies, guidelines and documents the hospital failed to ensure nursing care interventions were provided according to hospital guidelines and policies for the prevention of pressure ulcers for one of four patients reviewed for pressure ulcers, Patient 1 (P1) when repositioning was not done and the skin under the preventative dressing was not assessed according to hospital policies and guidelines and P1 developed a Stage 3 (full thickness skin loss where the damage extends through the dermis and into the subcutaneous tissue) pressure wound, and the hospital did not implement new measures to prevent recurrence. Findings included: On 07/22/25 at 11:06 AM the following hospital documents/policies were reviewed as follows: 1. “EDUCATION ESSENTIAL ...Think PINK - Pressure Injury Prevention Guidelines 09.2024” was reviewed. The document indicated, “To bring pressure injury prevention back to basics, the Think PINK initiative has been created ...Team members will use these guidelines to care for patients to prevent pressure injuries ...P - Pressure Injury Assessment ...Braden score - Patient is at risk for < 19 ...I - Initiate Interventions ...Reposition frequently ...Turn at risk patients q[every]2hours & unable to turn self ...Protect boney prominences with foam border dressings as needed per patient - peel back the dressings at minimum each shift to examine skin under the dressing ...” 2. “Skin Care Orders and Treatment Guidelines ...Effective Date ...06/25/2025 ...Initiate Think Pink Pressure Injury Prevention Guideline if Braden Score is <19 ...Wound Type ...Skin intact, is colored, non-blanching or maroon/purple discoloration ...Recommended Treatment Options ...Cleanse with normal saline or wound cleanser and pat dry. Apply foam dressing [e.g. Mepilex], peel back every shift for skin examination. Monitor closely for signs of deterioration. Avoid pressure to area if possible...” Review of Patient 1’s (P1’s) record on 07/22/25 at 11:59 AM with Registered Nurse 1 (RN1) revealed P1 was admitted to the hospital on 02/16/25. The admission History and Physical dated 02/16/25 indicated P1 was admitted to the hospital “to see ortho [orthopedics - medical specialty of the musculoskeletal system] with fever and left ankle swelling. ...Plan - being treated for possible infected hardware left ankle with immunosuppression due to renal transplant, diabetes (increased sugar in the blood) ...A1c 9.4% [blood test indicating the average of blood sugar levels over the past 2-3 months with normal being below 5.7%].” The Admission Nursing Assessment on 02/16/25 at 10:06 PM indicated P1 did not have any pressure wounds. Review of P1’s assessed risk of pressure ulcer development (Braden scale, 1-23 in which 15-18 is mild risk, 13-14 is moderate risk, and 10-12 is high risk) revealed from 02/19/25 to 03/02/25 P1 had the following risk for skin breakdown/pressure ulcer development: From 02/19/25 to 03/02/25, Braden score of 15-18 (mild risk) 13 of 21 days; From 03/04/25 to 03/21/25, Braden score of 15-18 on 3 of 33 days, 13-14 (moderate risk) 10 of 33 days, and 10-12 (high risk) 20 days out of 33 days. Continued review of P1’s record with RN1 revealed P1’s albumin (a protein found in the blood in which low levels are associated with an increased risk of developing pressure ulcers and normal range is 3.4 - 5.4 g/dL [grams per deciliter] was 1.9 on 03/11/25, 1.7 on 03/15/25 and 1.9 on 03/17/25. Record review continued on 07/22/25 at 2:40 PM and in a concurrent interview with RN1 she stated staff were supposed to reposition patients who required assistance every two hours. Continued review of P1’s record with RN1 revealed multiple instances P1 was not repositioned every two hours, including gaps greater than four hours. RN1 confirmed the following instances P1 was not repositioned for more than 4 hours: 03/12/25 from 1:09 PM to 6:00 PM (almost 5 hours) 03/12/25 from 6:00 PM to 03/13/25 8:00 AM (14 hours) 03/13/25 from 4:00 PM to 9:05 PM (5 hours) 03/14/25 from 4:02 AM to 9:00 AM (almost 5 hours) 03/14/25 from 9:00 AM to 7:32 PM (10.5 hours) 03/15/25 from 9:37 AM to 3:31 PM (almost 6 hours) 03/15/25 from 8:01 PM to 03/16/25 00:15 AM (4.25 hours) 03/16/25 from 10:30 AM to 03/16/25 8:00 PM (9.5 hours) During continued review of P1’s record with RN1, she stated a Mepilex (foam border dressing) was in use for P1 as a preventative measure. RN1 stated the nurses were supposed to assess under the dressing every four hours for patients with a Braden score of 18 or less. The Think PINK Guidelines (referenced in policy “Skin Care Orders and Treatment Guidelines”) indicated this was to be done each shift. RN1 confirmed there was no documented evidence the nurses assessed P1’s skin under the Mepilex dressing on the coccyx according to the Think PINK Guidelines and there was also no documented evidence the Mepilex dressing was in use on multiple days according to the hospitals Think PINK Guidelines from 03/10/25 to 03/18/25 (when P1’s Braden score was 14-10, moderate to high risk for developing pressure ulcers.) RN1 confirmed the findings and stated...”The greatest opportunities surround consistent turning with pressure relief and checking skin during BSSR [bedside shift report].” Continued review of P1’s record on 07/22/25 at 12:20 PM revealed the nursing assessment of the skin dated 03/19/25 indicated, “...bedsore to coccyx, covered with Mepilex by nurse...at 2000 [8:00 PM].” There was an order for a wound ostomy certified nurse (WOCN) consultation on 03/20/25 at 6:21 AM. Review of the WOCN note dated 03/20/25 at 12:39 PM revealed, “...Date first assessed 03/19/25 at 2000 [8:00 PM]...pressure injury...coccyx...wound bed description - fragile, moist, open, pink, tan, non-blanchable purple discoloration on left edge of wound...full thickness...pressure injury stage...3...length 3 cm [centimeters]...width...0.5 cm...depth 0.3 cm...drainage...serous [clear liquid]...applied and secured dressing...foam with border [Mepilex]...Recommend continued PIP [pressure injury prevention] interventions...” In an interview with RN1 on 07/23/25 at 1:02 PM, RN1 stated, “There was opportunity here. The nurses are supposed to assess under the Mepilex dressing” and she confirmed there was no documentation of the nurses assessing P1’s coccyx and repositioning P1 according to the policy “Skin Care Orders and Treatment Guidelines” and the Think PINK Guidelines referenced in this policy from 03/10/25 to 03/18/25. Observation of the Intensive Care Unit (ICU) was conducted on 07/23/25 at 1:30 PM to 2:00 PM. During an interview with Patient Service Technician 1 (PST1), at 1:46 PM, she confirmed they were supposed to turn patients every two hours if they needed help to reposition. During an interview with RN2 at 1:49 PM, she stated the nurses apply Mepilex dressings on patients on boney prominences and they were supposed to check the skin under the Mepilex dressings at the beginning and end of each shift. RN2 stated they were supposed to document that they assessed the skin under the Mepilex drssing in the integumentary section of the nursing documentation. RN3 was interviewed at 1:57 PM during the ICU observation. RN3 stated they use Mepilex as a preventtive especially for boney prominences. RN3 stated there were supposed to check the skin under the Mepilex dressings and document that assessment in the integumentary section of the nursing documentation.”