HospitalInspections.org

Based on record review, interview, pamphlet review, and policy review, the provider failed to ensure prompt response within 7 days per policy for four of four randomly reviewed grievances received from patients (43, 44, 45, and 46) or their family members. Findings include:

1. Review of patient 43's 8/17/15 Record of Complaint form revealed:
*Attached were copies of two letters sent to the guardian. Those letters revealed:
-On 9/21/15 the guardian had been informed by the quality risk management director that her concerns had been under investigation.
-On 10/22/15 the quality risk management director informed the guardian the results from that investigation.
*The guardian had not received a response from the provider regarding the investigation until thirty-five days after the provider received the grievance.

2. Review of patient 44's 9/2/15 Record of Complaint form revealed:
*A 10/12/15 letter to the guardian regarding areas of concern and the outcome from the investigation.
*The guardian had not received a response from the provider regarding the investigation until forty days after the provider received the grievance.

3. Review of patient 45's 9/8/15 Record of Complaint form revealed:
*A 9/21/15 letter to the guardian regarding areas of concern and the outcome from the investigation.
*The guardian had not received a response from the provider regarding the investigation until thirteen days after the provider received the grievance.

4. Review of patient 46's 9/19/15 Record of Complaint form revealed:
*Attached were copies of two letters sent to the guardian. Those letters revealed:
-An undated letter sent to the patient requesting more information from him to help "Complete a thorough review."
-On 9/17/15 the quality risk management director informed the guardian the results from that investigation.
*No documentation to support when the patient or guardian had been initially notified from the provider.

5. Interview on 11/18/15 at 1:00 p.m. with the quality risk management director confirmed the above grievances had not been responded to per the provider's policy.

Review of the provider's April 2014 Grievance Process policy revealed"
*"Each person filing a grievance will receive a response from the [hospital name] unless he/she has declined to identify him/herself within 7 days."
*"Resolution will be completed as soon as possible."

Based on record review, interview, pamphlet, and policy review, the provider failed to ensure that four of four randomly reviewed grievances received from patients (43, 44, 45, and 46) or their family members had been thoroughly investigated and documented. Findings include:

1. Review of patient 43's 8/13/15 Patient and Family Billing Questions/Clarification report revealed:
*The patient's guardian had called the provider and was angry.
*The "Item/procedure in question area" revealed the following:
-"Pt. [patient] came from [clinic name] admit."
-"At some point her appendix ruptured [burst, opened], had surgery."
-"The day of discharge pt was only eating popsicles & [and] no labs [laboratory tests] done to see if infection was gone."
-"Dr. [doctor] said there was no [no further information documented]."

Review of patient 43's 8/17/15 Record of Complaint form revealed:
*The back of the form identified several areas of concern by the patient's guardian.
*The guardian had concerns regarding the nursing department and the services they had provided during the patient's stay.
*Those areas of concern had been:
-Ineffective pain management prior to surgery for a ruptured appendix.
-The administration of medications through the patient's IV (intravenous) (fluid or medication given through a vein) by the nursing staff.
-The patient's diet during her stay at the hospital and upon discharge from the facility.
-The approach and comments made to the patient by unidentified nursing staff and the medical doctor.
*There was no documentation to support:
-Which director and department the grievance had been referred to.
-How the grievance was investigated and the findings from that investigation.
-The steps taken to correct the condition or grievance.
-The response by the family based on those investigation results.
-The grievance had been resolved.

2. Review of patient 44's 9/2/15 Record of Complaint form revealed:
*The guardian had concerns regarding the nursing department and the services the patient had received during his discharge from the facility.
*Those areas of concern had been:
-The length of time the patient had waited at the nurse's station waiting for transportation to the assisted facility.
-The poor communication between the discharging and admitting providers. The patient had been discharged without the use of oxygen. He had been very short-of-breath by the time he reached the assisted living facility. The assisted living facility was going to decline him as a resident because of his respiratory status upon admission.
*There was no documentation to support:
-How the grievance was investigated and the findings from that investigation.
-The steps taken to correct all of the areas of concern.
-The response by the family from those results of the investigation.
-The grievance had been resolved.

3. Review of patient 45's 9/8/15 Record of Complaint form revealed:
*The guardian had concerns regarding the care and services the patient had received from the provider's emergency department on 8/27/15.
*Those areas of concern had been:
-The approach and assessment made by the physician's assistant working in the emergency department that day.
-The patient had excruciating low back pain and had received pain medication. No diagnostic testing had been performed, because it was "Not a car accident, blunt force, etc." The patient had been discharged to home.
-The patient continued to have excruciating low back pain throughout the weekend. Five days later the patient had been admitted to another hospital with the diagnosis of a bulging disc.
*No documentation to support:
-Which director and department the grievance had been referred to.
-How the grievance was investigated and the findings from that investigation.
-The steps taken to correct the condition or grievance.
-The response by the family based on those investigation results.
-The grievance had been resolved.

4. Review of patient 46's 7/30/15 Patient and Family Billing Questions/Clarification form revealed:
*The patient's guardian had called the provider with concerns.
*The "Item/procedure in question area" revealed the following:
-"[Guardian] wondering why the nurse went by what the direct lab report of a urine culture showed, never did other things, asking about pain or no other test."
-"Patient was in extreme pain, and they did nothing to find out why."
-"Turns out two days later he went to clinic, had a ruptured appendix."
-"Spent eight days in the hospital."

Review of patient 46's 9/19/15 Record of Complaint form revealed:
*No documentation to support:
-Which director and department the grievance had been referred to.
-How the grievance was investigated and the findings from that investigation.
-The steps taken to correct the condition or grievance.
-The response by the family from those results of the investigation.
-The grievance had been resolved.

5. Interview on 11/18/15 at 1:00 p.m. with the quality risk management director revealed:
*She and the director of nursing discussed patient grievances and initiated the investigation process.
*She would have forwarded the grievance to the appropriate department directors. Those directors had been responsible to further investigate the grievances with their staff.
*When there had been grievances regarding the medical doctors a peer review would have been completed. The peer review was a committee consisting of other medical doctors.
*All documentation, interviews, and the investigative process the department directors completed for the grievances should have been given to her.
*She had not been able to provide documentation to support a full investigation of the nursing staff had been done on the above four grievances.
*She had agreed the investigative reports on the above four grievances had not been filled in correctly and completely.
*The patients would have received a pamphlet upon admission containing grievance information.
*The pamphlet had been included in a welcome packet located in the patient's room.
*She was not sure if the pamphlet had been reviewed with the patient by the nursing staff.
*She agreed the pamphlet had not explained the process on how the provider resolved a grievance.

Review of the provider's undated Patient Information pamphlet revealed:
*Information on grievances and the patient representative's responsibilities.
*The information provided had been: "A patient representative is available to make your visit at [hospital name] as positive as possible. The patient representative will help patients, families, and visitors with concerns, problems, early discharge concerns or complaints by explaining hospital policies and procedures and listening to suggestions."
*It had not addressed how the provider would resolve a grievance.

Based on observation, interview, testing, and procedure review, the provider failed to ensure the floors in the following locations were cleaned and disinfected appropriately between patients:
*One of five operating rooms operating room (OR 1).
*One of one cardiac catheter laboratory (cath lab).
Findings include:

1. Observation and interview with the director of surgery services on 11/18/15 at 9:45 a.m. in OR 1 revealed:
*There were at least three small BB sized spots of blood on the floor of operating room one. One at the foot of the bed, and two more several (approximately 4 to 5) feet from the left side of the bed.
*OR 1 had been used for a surgical procedure that morning.
*It had been cleaned, the floor had been mopped with a disinfectant, and it was ready for the next patient/procedure.
*She agreed the floor had not been appropriately cleaned.

2. Observation and interview with the director of the cath lab on 11/18/15 at 10:40 a.m. in that room revealed:
*There was a dime sized spot of blood on the floor near the head of the bed.
*The room had been cleaned and was ready for the next patient/procedure.
*During the cleaning procedure the floor should have been mopped.
*She directed an unidentified staff person to get a mop and clean up the blood.
*She indicated the floor had been mopped with water and not a disinfectant.
*Testing of the solution in the mop bucket where the mop head had been stored revealed it tested negative for quaternary ammonia, the type of disinfectant used by the hospital.
*They used water to mop the floor between patients and a disinfectant at the end of the day.

Review of the provider's undated Surgical/Invasive Areas and Delivery Rooms - Between cases procedure revealed:
*"Prepare germicidal solution as directed."
*"Use a mop dampened with germicidal solution to gather all debris from floor."
*"Wet mop the entire floor around the operating table and adjacent work areas using germicidal solution. Start with the area around and under the operating or delivery table."
*"Inspect the room."
*"Inspection standards - Floor is clean and free of dust, debris, blood, and body fluids."

Review on the provider's undated cath lab cleaning procedure revealed to "Wet mop floor." There were no other instructions in the procedure in regards to cleaning the floor.