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Review of the hospital's complaint/grievance policy and procedure, the hospital provided "patient admission information" and interview of the hospital complaint/grievance designee/patient representative on 01/16/14, it was determined that the hospital while having a complaint process outlined in policy and procedure, the mechanism or system of complaint or grievance resolution was not carried out as specified and according to federal regulation.
The findings were:
Observation and review on 01/16/14 at 2 PM of the hospital's "Patient Complaint Procedure" , R.M.7, effective 09/02/11, revealed that:
1) All patient complaints whether received in writing or verbally (2.2) shall be documented for the purpose of tracking to correct the problem areas identified through the process. A Customer Service Occurrence Report is generated in the hospital's Occurrence Reporting System (ORS) with a written response from the Administrative - level manager, designee or Patient Representative to the complainant.
The procedure (3.0, 3.1, and 3.2) outlines written letters of complaints and verbal complaints (Telephone or Direct). The complainant will be contacted (3.1.5) upon receipt of the complaint letter within 48 hours and a verbal or written response to the complainant will be conveyed within 7 working days. If the hospital investigation should take longer than 7 days then the complainant will be informed and given a tentative date of resolution.
The policy and procedure failed to: delineate, define, and describe what constitutes a complaint versus a grievance. There was not a separate " Grievance Policy", that identified a Grievance Committee, inclusive of the constellation of staff and functions, time frames and types of response to the complainant (process), an outline of resolution criteria based on the complexity of the issue(s), and follow up by staff in a written format in a stated number of days to the grievant for unresolved issues and status of the investigation.

Additional review of the hospital's, "Patient Complaint Procedure" revealed that there was no noted indication that the hospital's Governing Body had delegated the responsibility for the grievance process to a Grievance Committee.

2) Interview with Patient Representative on 01/16/14 at 2:30 PM revealed that the complainant had contacted the hospital on 11/8/13 with concerns about the patient's care. The complainant expressed satisfaction with the care the patient received for the 10 day hospital admission, but became very upset that the patient incurred a skin tear on 01/07/14 and that staff failed to inform the family. The patient representative stated she referred the complaint to the unit manager on the 6th floor. Per the patient representative's complaint file, the unit manager spoke to the complainant on 11/15/13 or 8 days after the patient was discharged. The hospital documented the complainant's concerns as a complaint and not a grievance. The complainant was not sent a resolution letter by the patient representative or other hospital staff. The entire process was handled over the telephone with documentation in the complaint file.


A hospital list entitled "Grievance Reporting 11/1/13-1/16/14 " was provided for review but the patient representative revealed that all the entries were treated as complaints. The review indicated that only 1/3 of the entries were actually complaints and the remainder grievances. None of the grievance files had resolution letters because they were treated as complaints.

The hospital failed to have in policy and procedure that the Governing Body delegated the complaint and grievance process to the hospital administration, risk management,and patient representative. Refer to A-0118 for the details.

The hospital failed to have in policy and procedure for the process by which a patient submits a written/verbal grievance. Refer to A-0118 for the details.

The hospital failed to have in policy and procedure delineating the time frames for review and response to the complainant/grievant. Refer to A-0118 for the details.

The hospital failed to have in policy and procedure the time frames for resolution of a grievance, written response to grievant, and date of completion. Refer to A-0118 for the details.

Observation and review of patient medical records and interview of the licensed nursing staff, it was determined that the nursing staff failed to ensure that patients care plans were updated and current with the patient 's needs with regard to discharge planning. This was evident for one out eleven sampled patient medical records reviewed.
The findings were:
Patient #1 was 86 years old with multiple medical conditions that included an altered mental status and seizures. The patient was admitted to the hospital on 10/27/13 from home and was discharged from the original hospital to another hospital on 11/07/13 for a higher level of care for evaluation and second opinion on care.
The receiving hospital's nursing staff upon the patient's admission and initial assessment on 11/07/13, discovered that the patient had a dressing applied to the right forearm. Removal of the dressing by the staff revealed that the patient had a "skin tear" or wound to the right inner forearm. The patient's family members were unaware of the "skin tear" to the patient's arm.
Interview of the first hospital's nursing staff on 01/16/14 at 12:40 PM revealed that an assigned nurse on the night shift had discontinued the patient's intravenous therapy (IV) site (due to leakage) and removed the bio-occlusive dressing at the site. During the discontinuing of the patient's IV and removal of the bio-occlusive dressing( a medical dressing that seals a wound from air, fluids while resisting penetration of viruses, bacteria, or other organisms at the site) on 11/07/13 at 05:00, the patient incurred a skin tear (3 x 2 )at the site. The nursing staff cleaned the skin tear with normal saline, applied Bacitracin ointment(antibacterial ointment) and a dressing ( Alleven-silicone padded medical dressing that promotes healing and minimizes maceration).
Further review of the patient's medical record and interview of the licensed nursing staff on 01/16/14 at 12:45 PM, it was revealed that the patient's family and attending physician were not notified by the nursing staff about the patient's skin tear to the right forearm. A review of the patient's discharge and transfer summary to the second hospital indicated that the skin tear was not noted.
The first hospital's nursing staff failed to: 1) communicate to the patient's family and attending physician about the patient's skin tear and 2) notifying the receiving hospital's staff about the patient's skin tear care. The lack of communication by the nursing staff and updating of the patient's care plan, potentially placed the patient for having a delay in treatment.