HospitalInspections.org

Based on review of facility documentation, policies and staff interviews it was determined the facility failed to provide a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of 1 (#1) of 5 sampled patients to investigate the grievance, the results of the grievance process, and the date of completion.

Findings included:

A review of the facility ' s Grievance log for 2010 revealed an entry was made on 8/3/10 for a Grievance filed for patient #1. Further review of the Grievance log did not reveal any other entries related to the patient for the year 2010.
A review of documentation related to the Grievance filed revealed the Grievance was logged into the system on 8/3/10 by the facility ' s administration. The Grievance was received as a letter and the desired outcome was listed as clarification and/or explanation. An investigation was initiated the same day by the executive assistant. On 8/4/10 the Director of Patient Care Services spoke with the complainant by phone and arranged a meeting on 9/1/10. The Director wrote in her report the complainant sounded satisfied with the outcome of the phone conversation. A follow-up e-mail was sent on 8/16/10 to the complainant from the Manager of the unit the subject had been admitted to. In the e-mail the Manager did mention she had attempted to contact the complainant and left messages several times but was unsuccessful. The Manager expressed her apologies and sympathy for the complainants' loss. The Grievance was closed after the Chief Operations Officer (COO) and the Director of Patient Care Services met with the complainant on 9/1/10. No further letters were sent.
An interview with the Director of Patient Care Services on 1/10/11 at approximately 3:00 p.m. revealed she had met with the complainant on 9/1/10 for the final meeting. At this meeting, the Director and COO discussed with the complainant her concerns. The Director also stated that the facility had scheduled further training for the staff on death/dying patients. They had also discussed the reason the subject had been moved was because the subjects physician had ordered a private room for the subject. At the time, the subject was moved the nursing staff had not felt the subject ' s condition had deteriorated to the point that death was imminent. When the meeting was over the case had been closed, the Director and COO felt the complainant was satisfied and the issues were resolved. Thus, no further letter or phone calls were made due to the case being closed.
A telephone interview was conducted on 1/12/11 at 12:20 p.m., with the Director of Patient Care Services regarding whether any letter had been sent to the complainant following the last meeting. After reviewing the records the Director reported that no further letters and/or contact were made with the complainant.

The facility ' s policy " Complaints-Customer Feedback " , policy # 100.101.01, effective date 6/2010 was reviewed on 1/10/11.
A review of page 2 of 5, section 4, titled Feedback Response and Resolution by Owner, paragraph g) feedback will receive a written response (letter) from the principal owner upon resolution: i) The letter will address the specific feedback received from the customer, ii) the letter must be reviewed by a Director or designate before being sent, iii) Other managers involved with the feedback will provide the owner with follow-up information within a five (5) business day period.

Based on clinical record review, staff interview, and patient family interview it was determined that nursing did not follow the Physician's orders to ambulate and get the patient out of bed for 1 (#5) of 5 sampled patients.

Findings include:

A review of patient #5's clinical records revealed a Physicians order dated for 1/5/11 at 6:00p.m., to get the patient out of bed, to ambulate and sit up in chair. This order was noted by nursing on 1/6/11 at 12:20 a.m. An order was written on 1/6/11 at 7:15 again to get the patient out of bed often. Another order was written on 1/6/11 at 1:00 p.m. to get patient out of bed to chair. A chart check was completed by nursing on 1/6/10 at 7:30 p.m. and 11:25 p.m. A Physicians order was written on 1/8/11 at 11:20 a.m. to get the patient out of bed to chair and to continue physical therapy. These orders were noted by Nursing at 11:20 a.m. A Physician ' s order was written on 1/9/11 at 3:20 p.m. to get the patient out of bed to chair and to ambulate three times a day. These were noted by Nursing during the 24 hour chart check at 11:40 p.m. on 1/9/11.
A review of the patients Nursing Clinical Flow Sheet page 2 of 8, under the heading " Activity " revealed Nursing had documented the patient was on bed rest from 1/5/11 to 1/10/11.
An interview was conducted on 1/10/11 at approximately 10:00 a.m. with the patient's family member. The family member commented the nursing care has been good except that the family wished the patient had been gotten out of bed more.
An interview was conducted on 1/10/11 at approximately 10:30 a.m., with the Unit Manager after she had reviewed the patients chart. The manager confirmed the written orders and lack of nursing to follow orders. The Nurse taking care of the patient stated the patient refuses to get up with Nursing, but confirmed there was no documentation by nursing to confirm this.