HospitalInspections.org

Based on document review and staff interview, the governing board failed to establish an effective grievance process for 1 of 2 patient grievance reviewed.

Findings include:

1. Review of the complaint/grievance log for January-present indicated that two (2)grievances/complaints were filed by the family of patient #N1 as follows:
(A) A family member notified the hospital on 2/23/11 with complaints including, but not limited to, his/her parent had to "bang on the bed for help" and the patient (#N1) required a cane to ambulate and staff ignored their requests during a recent ED visit.
(B) A family member notified the hospital on 2/28/11 with a complaint that during the ED visit, patient #N1 had two (2) necklaces missing.

2. The facility patient relations worksheet indicated that the complaints/grievances were resolved on 3/21/11.

3. A letter sent to patient #N1 on 3/1/11 indicated the facility was following up on the two necklaces that were lost. The letter did not address the complaint that the patient had to bang on the bed for assistance or that he/she was not provided with a cane for ambulation during the ED visit.

4. Facility policy titled "Complaint Resolution for Patients/Visitors" last reviewed/revised 12/09 states on page 1: "3. To treat all complaints and grievances as an opportunity to improve upon the quality of services provided, and to treat any person expressing a complaint or grievance with dignity and respect......" Page 3 states: "3. Managers/Directors or their designated representative, will handle each complaint on an individual and timely basis, taking into consideration the nature of the grievance and any factors that might endanger patient safety, and will:..............B. Investigate the complaint, or arrange for such investigation, involving all appropriate hospital/medical staff as needed." Page 4 states: "Once the Staff Member or Manger has completed their investigation, they will communicate, verbally if possible, the response and/or resolution with the patient and/or visitor as well as with the hospital and medical staff involved, and document such response in Section II of the Customer Complaint Documentation Form."

5. Staff member #P2 indicated the following during interview beginning at 3:15 p.m.:
(A) The patient safety issue that the patient had to "bang on the bed for help" in the complaint received by the hospital for patient #N1 had not been addressed.

Based on observation and staff interview, the facility failed to maintain a safe environment for 2 of 19 emergency department (ED) bays/rooms observed.

Findings include:

1. During tour of the ED beginning at 10:30 a.m. and accompanied by staff members #P1, P2, P3 and P4 the following was observed:
(A) Fast track room C did not have a call light for a patient to summon staff if needed and the room was not taken out of service.
(B) Hall bay #3 had a working call light that rang to a phone carried by a staff member, however there was no staff member carrying the phone that the call light was connected to or would ring to.

2. Staff member #P1 indicated the following in interview beginning at 2:15 p.m.:
(A) He/she verified that fast track room C had no call light and that no staff had the phone that the call light from hall bed/bay #3 was connected to or would ring to.