Select Specialty Hospital - Charleston

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 43434 Based on policy, document review and staff interviews, the facility failed to complete the resolution action process to a grievance in a timely manner (patient 1). This deficiency has the potential to affect all patients that file a grievance. Findings: A policy titled “COMPLAINT AND GRIEVANCE PROCESS”,issue date 1/1/26, was reviewed. The policy states in part, “...8. All Patient Grievance investigations, follow-up actions, and written responses will be completed within seven [7] days of receipt of Grievance. If the Grievance will not be resolved or the investigation will not be completed within seven [7] days, the patient/family will be notified in writing that the investigation and/or resolution will take additional time. If additional time is required, it will not exceed beyond 30 [thirty] days from receipt of the grievance ... 12. The written response must contain the following: a. A description of the issues raised by the grievance. b. A description of the steps taken to investigate the issue. c. The date the grievance was resolved and what steps were taken to resolve the grievance. d. The name of a contact person at the hospital that the patient can call with additional questions...” A policy titled “PATIENT RIGHTS AND RESPONSIBILITIES” was reviewed, no review date. The policy states in part, “... 3. Grievances. You have the right to receive considerate and respectful care in a clean and safe environment. You will be encouraged and assisted throughout the period of stay to exercise your rights as a patient and as a citizen. You may voice grievances and recommend changes in policy and services to the Hospital staff, to an individual designated by the Hospital for such purposes, or to outside representatives of your choice. The Hospital’s Patient Representative functions as the primary contact to receive complaints from patients regarding Hospital services. You or the individual designated to the Hospital will be made aware of the state Department of Health to which you may address grievances... 18. Complaints. Questions, comments, or complaints concerning these rights or the application of these rights should be addressed promptly to the Administrator of this Hospital or the Hospital’s Patient Representative. Instances concerning potential abuse are to be brought to the administrator’s attention immediately, without regard to the time of day...” A review of the grievance filed on 1/6/26 and the investigation letter dated 1/8/26 was completed. The grievance and a computerized version of the grievance was provided. The letter to the patient attached to the investigation document states in part, “The following steps have been taken to investigate your concerns: Clinical staff involved in your [family members’] care were interviewed. Your [family members] medical record, including [his/her] plan of care, was reviewed. The following issues that you identified will be summarized: You expressed concern that your [family member] did not receive a blood transfusion in a timely manner. You expressed concern that your [family member] is not being bathed regularly. You felt that your [family member] has a wound that is not healing. You stated that you would like your [family member] transferred to another hospital. Our investigation concluded on January 7, 2026, and as a result the following actions were taken: Staff were re-educated on Select’s expectation to effectively communicate delays in medical interventions to families. All staff are being re-educated regarding Select’s expectation to provide patient care as ordered and in a timely manner. The Wound Care Nurse was re-educated on the importance of providing education on wound care and the healing process to patients and their families. You and your [family member] were provided with all the information needed for your [family member] to transfer to another facility”... There were no other documents, interviews or training documentation within the investigation.” A review of “Job Description Director of Quality Management” was completed. Job Summary: The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including but not limited to: Risk Management. Quality Improvement, Survey Readiness, Infection Control, Employee Health and Education. JOB SPECIFIC DUTIES/COMPETENCIES: ... 9. Follows Risk Management Incident Reporting Policy. Completes timely review of all incidents and assigns severity level. ... 20. Focuses on the importance of employee training and education in the workplace. Facilitates general orientation with HRC and participates in annual education activities as indicated. Maintains a presence in the clinical area... 23. Assist department managers and the implementation of policies and procedures...” An interview was conducted on 3/24/26 at 3:29 p.m. with staff 3. Staff 3 stated, “I was being trained for the role of Director of Quality by [staff 4]. [Staff 4] was brought in from another location to train me. I was doing and following [staff 4’s] lead. I had a staff meeting after the investigation and talked about the investigation outcome but there was no actual training on it. I’m not sure, I am new to the job and didn’t know. No, none of the staff have been trained on the issues identified in the investigation.” An interview was conducted on 3/25/26 at 11:00 a.m. with staff 3. Staff 3 stated, “We [staff 1 & staff 4] received from [staff 7] a complaint regarding the delay in getting the transfusion for the patient [patient 1]. [Staff 4] and I called the complainant twice but couldn’t get [him/her]. Left a message for the family member to contact us. We then called the medical power of attorney (MPOA) for the patient to discuss the complaint. We already had some concerns voiced about wound care and bathing, so we wanted to let the MOPA know that the transfusion delay had been added to the complaint and we had transitioned the complaint into a grievance. We started an investigation on 1/7/26 we looked into the situation with the bathing and wound care. I was being trained for the job by [staff 4], I don’t know why there isn’t investigative notes and interviews in the investigation. On 1/8/26 we conducted an investigation into the delay of blood transfusion. We interviewed staff, reviewed the chart and we had already reviewed flow sheets. On 1/8/26 we met with the family and presented the family our findings and outcomes. The staff would be retrained on wound care, following orders, personal care and notifying the family of changes and updates. At that time the MPOA signed off on the investigation and resolution, and we thought everything was resolved. There was a staff meeting where those topics were gone over. No, everyone wasn’t retrained. No, we didn’t do our follow up action. I don’t know why there weren’t nursing notes regarding the delays and things. There should have been charting that let others know what was going on.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 43434 Based on policy, documentation review and staff interviews, the facility failed to provide nursing supervision by not ensuring nursing compliance with physician order (patient 1). This deficiency has the potential to affect all patients receiving services. Findings: A policy titled “Orders and Protocols”, revised 4/1/23, states in part, “POLICY: Orders will be entered in the medical record by a Licensed Practitioner (LP) such as a credentialed physician or other credentialed practitioner. All patient medication, therapy, diet, testing, and/or invasive procedures must be ordered by a LP. Orders will be reviewed and carried out appropriately by facility staff. When computerized provider order entry (CPOE) is available, orders should be entered electronically by an LP... PROCEDURES: 1. General Procedures...C. Orders must be complete and include all required components. If an order is unclear or incomplete, the ordering LP will be contacted. A clarification order will be entered in the medical record as appropriate...E. Stat Orders should be administered within 30 [thirty] minutes of the order being placed. NOW orders should be administered within one [1] hour of the order being placed...H. Nurse will review all orders within the assigned patient group prior to the end of shift and notify oncoming staff of incomplete orders and progress, implementing any new orders placed on previous shift. II. Protocol orders A. All protocols will be presented to the Medical Executive Committee and Governing Board for review and approval...C. That will be educated as to the approved protocols. D. Copies of approved protocols are available to staff (paper or electronic). E. An LP order must be entered in the medical record to initiate any protocol, unless it is approved as a standing protocol (standing order) by the Medical Executive Committee of the Hospital for all patients... F. Protocols should be executed and/or followed based on licensure and scope of practice... H. When a protocol step is implemented that represents a progression or regression in care or treatment such as a diet, therapy, wound care, medication regimen (see exclusion for titrate orders), etc [etcetera], the appropriate practitioner must enter an order in the medical record. These must be dated, timed and authenticated by the clinician executing the protocol...” A policy titled “BLOOD/BLOOD COMPONENTS ADMINISTRATION (PACKED CELLS, PLASMA, PLATELETS, CRYOPRECIPITATE)” revised 10/1/25 states in part, “PURPOSE: To establish a policy and procedures for the safe administration of blood and/or blood components ...POLICY: ... 5. If an in-house blood bank is not available, the Hospital will utilize a contracted blood bank for their blood product needs. 6. Type and crossmatch is required for Packed red blood cells (PRBC): a. Type and screen MUST be performed. b. Red cell type must be compatible with that of the patient. c. Uncrossmatched RBC (red blood cell) are not in administered in our facility: should a patient require Emergent PRBC (packed red blood cells) due to excessive blood loss; such patient would be considered unstable and would be sent to an Acute Care Facility via EMS (emergency medical service)” ... A review of a job description titled “Director of Quality Management” was completed. Job Summary: The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including but not limited to: Risk Management. Quality Improvement, Survey Readiness, Infection Control, Employee Health and Education. JOB SPECIFIC DUTIES/COMPETENCIES: ... 9. Follows Risk Management Incident Reporting Policy. Completes timely review of all incidents and assigns severity level. ... 20. Focuses on the importance of employee training and education in the workplace. Facilitates general orientation with HRC and participates in annual education activities as indicated. Maintains a presence in the clinical area. 23. Assist department managers and the implementation of policies and procedures...” It should be noted the Director of Quality Management is a Registered Nurse (RN) A review of a job description titled “Registered Nurse” was completed and states in part, “Job summary: The Registered Nurse (RN) maintains the delivery of quality care by assuring the nursing care plan is followed. The RN supervises Licensed Practical Nurses, Certified Nursing Assistants and orientees. In collaboration with the physician, the RN assures implementation of the assessment plan, evaluation, and follow up of the plan of care for the patient population. JOB SPECIFIC DUTIES/COMPETENCIES:...10. Assures that medical orders are transcribed and processed accurately and integrates the medical care plan into the provision of nursing care... 23. Adheres to established policies and procedures of the hospital and Nursing Department...27. Acquires continuing education sufficient to maintain licensure and certification. Maintains current nursing licensure. Maintains required competencies as defined by SERC. Completes appropriate level of Clinical Advancement within established timeframes.” A review of the medical record for patient #1 revealed, Lab values showed as follows: Hemoglobin was 6.3 and flagged as critical. The results were called to [staff 5] on 1/5/26 at 2:58 p.m. At 4:58 p.m. a Compatible Crossmatch typing, antibody screen was ordered. Antibody identification on 1/5/26 at 9:19 p.m. Order comments: BB Antibody ID, Reflex order, ABSC positive. On 1/6/26 at 3:53 a.m., Compatible Crossmatch was ordered. Order comments: Antibody Identification: Anti-JkA 01*1, BB antibody ID Reflex order, ABSC positive. On 1/6/26 at 1:10 p.m. Hemoglobin Order, Hemoglobin 6.6, Flagged Critical. Result Comments: Critical Result HGB 6.6, Called to and read back by [staff 14] on 1/6/26 at 1:29 p.m. 1/6/26 at 1:40 p.m. Order for Transfusion-Product Ready. Crossmatch Tag completed on 1/6/26 at 5:13 p.m. 1/6/26 at 9:25 p.m. an order was completed for Hemoglobin and Hematocrit. Results: Hemoglobin 8.5 Flagged Low, Hematocrit 24.7 Flagged Low. Review of “Physician Orders” on 1/5/26 at 2:39 p.m. a routine Complete Blood Count with Differential (CBC w/Diff) was ordered. A review of “Physician Orders” for 01/05/26 at 3:20 p.m. Type and screen and give 1 [one] unit of PRBC [Packed Red Blood Cells]. It should be noted the RBCs were not given until 01/06/26 due to inaccurate orders placed by staff #5 and staff #3 was asked for instructions and did not stay to monitor staff #5. An interview was conducted on 3/24/26 at 8:30 a.m. with staff 3. “[Staff 5] was talking about needing labs when I was at the nursing station. [He/She] wanted to know the process. I told [him/her] to get a brown envelope, pink tubes, blood band, and multiple Cerner stickers, place a Cerner sticker on blood bands and envelope. Then, I explained the process that’s all the interactions I had with [him/her] and I left the unit...” An interview was conducted on 3/24/26 at 9:50 a.m. with staff 5. Staff 5 stated, “I only had the patient a few times. I’m not sure I remember. I don’t remember labs or blood transfusion. Process for an order is that the doctor usually puts them in. We watch for orders to pop up in the Epic system. We make sure there is patient consent and click that we acknowledge the order. We do the typing, screening and call the lab that we are sending it down. The lab usually calls the charge nurse and lets us know it’s ready. I wait maybe an hour before I tell the charge nurse, or I call the lab to see what the delay is. I’m not sure what to do if there is a major delay in getting results. I don’t know if there is a policy about that. Did the family complain, I really don’t think the family complained. I can’t be sure. I really don’t remember if there was a reeducation done”. An interview was conducted on 3/25/26 at 2:15 p.m. with staff 1. Staff 1 stated, “I was not aware that [staff 5] had asked [staff 3] what the process was for placing orders. I didn’t know this. The nurses on the unit are very good at assisting others and walking them through processes. Sometimes the new RN’s get confused because the policy and the procedure are different. We follow the procedure of the lab. The lab has its own policies and procedures because they are under a different hospital rule. It upsets me that we had a new RN asking for help and it wasn’t provided. It should have been handled differently. My expectation is that any nurse that is asked for help would take the opportunity to teach and assist a new nurse. In this case, it makes me sad because I wouldn’t think that [staff 3] would not assist and instruct [him/her] through the process”.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43434 Based on policies, documentation review and staff interviews, nursing failed to follow physician orders for a blood transfusion that delayed patient treatment (patient 1). This deficiency has the potential to affect all patients that receive services at the facility. Findings: A policy titled “Orders and Protocols”, revised 4/1/23, states in part, “POLICY: Orders will be entered in the medical record by a Licensed Practitioner (LP) such as a credentialed physician or other credentialed practitioner. All patient medication, therapy, diet, testing, and/or invasive procedures must be ordered by a LP. Orders will be reviewed and carried out appropriately by facility staff. When computerized provider order entry (CPOE) is available, orders should be entered electronically by an LP...PROCEDURES: 1. General Procedures...C. Orders must be complete and include all required components. If an order is unclear or incomplete, the ordering LP will be contacted. A clarification order will be entered in the medical record as appropriate...E. Stat Orders should be administered within 30 [thirty] minutes of the order being placed. NOW orders should be administered within one [1] hour of the order being placed...H. Nurse will review all orders within the assigned patient group prior to the end of shift and notify oncoming staff of incomplete orders and progress, implementing any new orders placed on previous shift...” A policy titled “BLOOD/BLOOD COMPONENTS ADMINISTRATION (PACKED CELLS, PLASMA, PLATELETS, CRYOPRECIPITATE)” revised 10/1/25 states in part, “PURPOSE: To establish a policy and procedures for the safe administration of blood and/or blood components ...POLICY: ... 5. If an in-house blood bank is not available, the Hospital will utilize a contracted blood bank for their blood product needs. 6. Type and crossmatch is required for Packed red blood cells (PRBC): a. Type and screen MUST be performed. b. Red cell type must be compatible with that of the patient. c. Uncrossmatched RBC (red blood cell) are not in administered in our facility: should a patient require Emergent PRBC (packed red blood cells) due to excessive blood loss; such patient would be considered unstable and would be sent to an Acute Care Facility via EMS (emergency medical service)” ... A policy titled “CRITICAL TEST RESULTS” revised 01/26 states in part, “PURPOSE: To provide a systematic approach for timely communication of critical test results among healthcare professionals. If necessary, based on Contracted Lab Requirements, there may be an addendum to this policy. POLICY: Definition: Critical test will be defined as: a. Lab Values traditionally described as ‘panic values’ that is results that indicate a real or potential emergent situation for the patient (high potassium, very low H/H) ... Critical Test Reporting and Monitoring: 1. A critical test is one that, regardless of results, is ALWAYS called to the responsible Physician or LP (Licensed Practitioner). 2. From a Quality Monitoring standpoint, time is tracked from time of order, time of results availability, and time of Physician or LP (Licensed Practitioner) notification...Communication Responsibility: 1. The RN, RT, or RPH who receive the critical test result will be responsible for accurate and timely communication of critical value and test results to the appropriate licensed practitioner” ... A review of a job description titled “Registered Nurse” was completed and states in part, “Job summary: The Registered Nurse (RN) maintains the delivery of quality care by assuring the nursing care plan is followed. The RN supervises Licensed Practical Nurses, Certified Nursing Assistants and orientees. In collaboration with the physician, the RN assures implementation of the assessment plan, evaluation, and follow up of the plan of care for the patient population. JOB SPECIFIC DUTIES/COMPETENCIES:...10. Assures that medical orders are transcribed and processed accurately and integrates the medical care plan into the provision of nursing care... 23. Adheres to established policies and procedures of the hospital and Nursing Department...” A review of the medical record for patient #1 revealed, Lab values showed as follows: Hemoglobin was 6.3 and flagged as critical. The results were called to [staff 5] on 1/5/26 at 2:58 p.m. At 4:58 p.m. a Compatible Crossmatch typing, antibody screen was ordered. Antibody identification on 1/5/26 at 9:19 p.m. Order comments: BB Antibody ID, Reflex order, ABSC positive. On 1/6/26 at 3:53 a.m., Compatible Crossmatch was ordered. Order comments: Antibody Identification: Anti-JkA 01*1, BB antibody ID Reflex order, ABSC positive. On 1/6/26 at 1:10 p.m. Hemoglobin Order, Hemoglobin 6.6, Flagged Critical. Result Comments: Critical Result HGB 6.6, Called to and read back by [staff 14] on 1/6/26 at 1:29 p.m. 1/6/26 at 1:40 p.m. Order for Transfusion-Product Ready. Crossmatch Tag completed on 1/6/26 at 5:13 p.m. 1/6/26 at 9:25 p.m. an order was completed for Hemoglobin and Hematocrit. Results: Hemoglobin 8.5 Flagged Low, Hematocrit 24.7 Flagged Low. Review of “Physician Orders” on 1/5/26 at 2:39 p.m. a routine Complete Blood Count with Differential (CBC w/Diff) was ordered. A review of “Physician Orders” for 01/05/26 at 3:20 p.m. Type and screen and give 1 [one] unit of PRBC [Packed Red Blood Cells]. It should be noted the RBCs were not given until 01/06/26 due to inaccurate orders placed by staff #5. An interview was conducted on 3/24/26 at 9:50 a.m. with staff 5. Staff 5 stated, “I only had the patient a few times. I’m not sure I remember. I don’t remember labs or blood transfusion. Process for an order is that the doctor usually puts them in. We watch for orders to pop up in the Epic system. We make sure there is patient consent and click that we acknowledge the order. We do the typing, screening and call the lab that we are sending it down. The lab usually calls the charge nurse and lets us know it’s ready. I wait maybe an hour before I tell the charge nurse, or I call the lab to see what the delay is. I’m not sure what to do if there is a major delay in getting results. I don’t know if there is a policy about that...I can’t be sure. I really don’t remember if there was a reeducation done.” An interview was conducted on 3/24/26 at 10:27 a.m. with staff 15. Staff 15 stated, “The charge nurse usually puts in the orders and we do the draws. It’s all in the computer, the lab and nurses can see it. You have to go in, and mark collected with time and date. Then you send it down to the lab. In about fifteen [15] to twenty [20] minutes, we call to make sure they received it. We get the results either by computer or the lab calls us and we notify the doctor. If there is something unusual or weird Epic has a box, you can document in.””