HospitalInspections.org

Based on document review, policy review and staff interview it was determined the Vice President of Patient Services and the Director of Human Resources failed to follow the hospital's process for doing a complete investigation of a grievance on patient abuse with proper investigation of staff who cared for a patient (patient #1), for one (1) of two (2) charts reviewed. This failure has the potential to adversely impact all patients that wish to file a complaint or grievance in this facility.


1. Review of documentation revealed a grievance was filed on patient #1's behalf on 7/11/16. The hospital documented the complaint as a grievance. During the course of the hospital's investigation no interviews were conducted with the hospital staff that cared for patient #1 during his hospitalization.

2. Review of the policy titled "Investigations of Patient Allegations of Abuse, Neglect or Exploitation by Persons Employed by or Representing SMMC", with a review date of 9/2015, states "Any investigation involving a staff member must be copied to the Director of Human Resources".

3. Review of the complaint policy titled "Concerns/Complaints/Grievance Process", with a review date of 8/15, states "Management will, in coordination with the Patient Advocate...Interview the complainant and document the interview...Confer with the nursing staff, social worker, physician, or other medical team members involved in the complaint...Complete appropriate documentation and forward to the patient advocate".

4. An interview was conducted on 8/2/16 at 7:15 a.m. with the Accreditation and Patient Safety Officer. When asked what extent the staff taking care of the patient were questioned in relation to the complaint she stated: "It's my understanding no staff were interviewed".

5. An interview was conducted on 8/2/16 at 9:00 a.m. with the Director of Medical-Surgical Department. When asked her level of involvement in the complaint process for the patient #1 she stated: "It showed up in Midas (our computer program) a chart review was conducted due to the patient being discharged. Then it went to the Director of Human Resources and the Vice President of Patient Services. When asked if any staff were interviewed or just a chart review she stated: "It is my understanding no staff involved in the patient's care were interviewed".

6. An interview was conducted on 8/3/16 at 8:10 a.m. with the Vice President of Patient Services. When asked what her expectations were when a complaint investigation occurs she stated: "I believe nursing staff, Directors and the manager investigate the complaint and conduct staff interviews and then all of the information would be placed in Midas so we can stay in contact with the patient or family". She concurred that no staff were interviewed that came in contact with patient #1.

Based on record review, review of policies and procedures and staff interview it was determined the Nurse Manager of Neurology failed to supervise nursing care in relation to a grievance filed involving abuse, this occured in one (1) of one (1) allegation of abuse on the Neurology Unit. This failure has the potential to adversely impact all patients that file a complaint for abuse allegations.

1. Review of documentation revealed a grievance was filed on patient #1's behalf on 7/11/16. The hospital documented the complaint as a grievance. During the course of the hospital's investigation no interviews were conducted with the hospital staff who cared for patient #1 during his hospitalization.

2. Review of the policy titled "Investigations of Patient Allegations of Abuse, Neglect or Exploitation by Persons Employed by or Representing SMMC", with a review date of 9/2015 states: "Any investigation involving a staff member must be copied to the Director of Human Resources...the complaint will immediately be given to the nurse manager...the appropriate documentation according to the customer concern/complaint/process shall be immediately completed".

3. Review of the complaint policy titled "Concerns/Complaints/Grievance Process", with a review date of 8/15, states: "Management will, in coordination with the Patient Advocate...Interview the complainant and document the interview...Confer with the nursing staff, social worker, physician, or other medical team members involved in the complaint...Complete appropriate documentation and forward to the patient advocate".

4. An interview was conducted on 8/2/16 at 7:15 a.m. with the Accreditation and Patient Safety Officer. When asked to what extent the staff taking care of the patient were questioned in relation to the complaint, she stated: "It's my understanding no staff were interviewed".

5. An interview was conducted on 8/2/16 at 9:00 a.m. with the Director of Medical-Surgical Department. When asked her level of involvement in the complaint process for patient #1 she stated: "It showed up in Midas (our computer program) and a chart review was conducted due to the patient being discharged. Then it went to the Director of Human Resources and the Vice President of Patient Services. When asked if any staff were interviewed or was it just a chart review she stated: "It is my understanding no staff involved in the patient's care were interviewed".

6. An interview was conducted on 8/3/16 at 8:10 a.m. with the Vice President of Patient Services. When asked what her expectations were when a complaint investigation occurs she stated: "I believe nursing staff, Directors and the manager investigate the complaint and staff interviews to occur and then all of the information would be placed in Midas so we can stay in contact with the patient or family". She concurred that no staff were interviewed that came in contact with patient #1.

7. An attempt to interview the Nurse Manager of Neurology was made and she was unavailable due to being on vacation.