HospitalInspections.org

Based on interview, record review, and review of facility policy it was determined that the facility did not provide written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 5 out of 5 sampled patients. (Patient identifier: 9, 10, 11, 12, 13)

Findings include:

On 10/16/18, a sample of 5 patient complaint/grievances was reviewed. There was no documentation that a letter containing the required elements had been sent to 5 out of 5 complainants.

On 10/16/18 at 10:32 AM, an interview was conducted with the Vice President of Quality, who is over complaints/grievances. When asked if he sends out letters to complainants containing these elements he responded, "we do not send out a letter if the issue is resolved, if it does not get resolved, we send out a letter." A sample letter they send out was requested and reviewed. The letter did not contain any of the required elements.

On 10/16/18, the "Patient Grievance Policy" was reviewed. It stated, "Written notice of Uintah Basin Healthcare's decision, that contains the name of the Corporation's contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, will be provided to the patient representative." However, the Vice President of Quality was not aware that a letter containing those elements needed to be sent to every complainant.

Based on interview and record review, it was determined that the facility did not ensure the nursing staff developed and kept a current nursing care plan for 13 of 13 sampled patients.
(Patient identifiers: 1-8, 10, and14-17.)

Findings include:

1. During record review, surveyors were unable to locate nursing care plans and asked the nurse manager of the medical/surgical and intensive care units (ICU) how to find the nursing care plans in the electronic medical records. The nurse manager of the medical/surgical and ICU stated that the the hospital did not have nursing care plans.

2. In an interview with the nurse manager of the ICU and medical/surgical units on 10/16/18 at 2:15 PM, surveyors asked if the nursing care plans could be found under a different title (for example, nursing goals or interventions) and the nurse manager again stated that the hospital did not have nursing care plans in any form.

3. Surveyors went to the hospital floors to interview patients on 10/17/18. The nurses of patient # 14 through patient # 17, each stated that there were no nursing care plans for these, or any, patients.

4. In a follow up interview with the nurse manager of the ICU and medical/surgical units on 10/17/18 at 11:45 AM, the nurse manager stated that order sets are placed into the medical record by each patient's physician and include a section titled "cares." She also stated that the daily process at the hospital is for nursing staff to make rounds as part of an interdisciplinary group; however, she stated that at no point were nursing care plans created by nursing staff.