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A. Based on review of hospital documents and staff interview the hospital failed to utilize the complaint resolution process for one (1) of one (1) patients reviewed who had complaints registered (patient #1). This failure creates the potential for the violation of the rights of all patients. Findings include:

1. Review of the hospital complaint files for 2010 revealed no complaints recorded related to patient #1.

2. An interview was conducted with the Admissions Coordinator in the morning of 4/27/10. She confirmed that complaints had been registered, related to the care and treatment of patient #1 since the first of the year, which were not addressed by the hospital's complaint resolution process.

3. The policy "Patient Grievance Procedure," last revised 6/14/06, was provided for review. It states in part: "Patients, hospital staff, or responsible parties may communicate grievances and concerns ...Grievance may be registered by telephone, mail, office visit, or by communications with staff."

B. Based on review of hospital documents and staff interviews, the hospital failed to inform patients how to contact the State Agency to file a grievance. This failure creates the potential for the violation of the rights of patients. Findings include:

1. Review of the patient admission packet and handbook revealed no documentation of contact information or instructions for contacting the State Agency to file a grievance.

2. During an interview with the Director of Quality in the late morning of 4/27/10, this finding was reviewed and discussed. She agreed with this finding.

Based on review of medical records, hospital documents and staff interview it was determined the hospital failed to ensure the performance improvement process analyzed the cause of a fall which resulted in a hip fracture for one (1) of one (1) patients reviewed with a fracture (patient #2). This failure creates the potential for a recurrence. Findings include:

1. During tour of the A3 unit on 4/26/10 in the late morning, patient #2 was identified as having a hip fracture. Review of the medical record revealed the patient fell in the bathroom on 4/2/10. An x-ray on 4/2/10 was read as negative. On 4/7/10 a repeat x-ray identified a hip fracture.

2. Interview was conducted with the Nurse Manager in the late morning of 4/26/10 related to the circumstances of the fall. She stated the patient got up quickly and tripped over her houseshoes which were poorly fitting. She noted the patient was accompanied by staff at the time of the incident.

3. The policy, "Management of Sentinel Events," last revised 3/26/08, revealed in part the following: "Mildred Mitchell-Bateman Hospital is committed to providing a safe environment for patients, employees, volunteers, and visitors. This is achieved by encouraging the reporting of adverse occurrences, hazardous conditions, sentinel events, near miss and significant events. An appropriate review of these occurrences and events that indicate a serious problem in hospital operations will be conducted to analyze why the problem occurred and what could be done to prevent a recurrence...Adverse Event: An untoward, undesirable, and usually unanticipated event. Incidents such as patient falls with injury or medication events are also considered adverse events even if there is no permanent effect on the patient, and followed through existing procedures...Adverse events, accidents and errors which are not sentinel events will be investigated and prioritized through established mechanisms such as the Incident Review Process and reported through the Performance Improvement Committee and the Medical Executive Committee."

4. In the morning of 4/28/10 a request was made for the investigation/conclusions made regarding the cause of the hip fracture. The Director of Quality Advancement could provide no documentation of an analysis of the cause beyond the preliminary finding regarding the ill-fitting house shoes.

5. Additionally, the hospital provided no documentation related to a performance review of the initial X-ray reading which indicated no fracture.

Based on review of medical records, hospital documents and staff interview it was determined the hospital performance improvement process failed to implement preventive actions and mechanisms related to circumstances which resulted in a fall with hip fracture. This failure impacted one (1) of one (1) patients reviewed who had a fracture (patient #2) and has the potential to adversely impact the quality of care of all patients. Finding include:

1. During tour of the A3 unit on 4/26/10 in the late morning, patient #2 was identified as having a hip fracture. Review of the medical record revealed the patient fell in the bathroom on 4/2/10. An x-ray on 4/2/10 was read as negative. On 4/7/10 a repeat x-ray identified a hip fracture.

2. Interview was conducted with the Nurse Manager in the late morning of 4/26/10 related to the circumstances of the fall. She stated the patient got up quickly and tripped over her houseshoes which were poorly fitting. She noted the patient was accompanied by staff at the time of the incident.

3. During the morning of 4/28/10 a request was made to both the Director of Quality Advancement and the A3 Nurse Manager for documentation of any preventive actions which were implemented as a result of the analysis of the cause of the fracture. Neither provided any documentation of actions taken.

Based on medical record review and staff interview it was determined the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for one (1) of one (1) patients reviewed who had a fracture (patient #2). This failure has the potential to adversely impact the care of all patients who have a change of condition. Findings include:

1. During tour of the A3 unit on 4/26/10 in the late morning, patient #2 was identified as having a hip fracture. Review of the medical record revealed the patient fell in the bathroom on 4/2/10. An x-ray on 4/2/10 was read as negative. On 4/7/10 a repeat x-ray identified a hip fracture. The record revealed the patient was transferred to another hospital on 4/7/10 for surgical intervention. The patient returned to the facility on 4/12/10.

2. A joint interview was conducted with both the A3 Nurse Manager and the Director of Social Work in the late morning of 4/28/10. Discussion revealed the nursing care plan is included in the patient's Master Treatment Plan. They acknowledged the patient's 4/5/10 Master Treatment Plan had not been updated to reflect the current nursing needs related to the patient's hip fracture.