HospitalInspections.org

Based on the review of eight grievance files submitted to the hospital from July 2018 until October 2018, grievance tracking log, and policies and procedures during the survey on 11/8/18, it was found that 2 of 8 files remained unresolved and the hospital had failed to respond to the grievance submitters and failed to adhere to their policy on Complaint/ Grievance.

Grievances #1 and #8 lacked documentation that the hospital acknowledged receipt of the grievance, or provided the submitter with an anticipated completion date.

The hospital's "Complaint/Grievance Program" (effective 8/17) stated in part, " ...Within 10 calendar days of the receipt of the patient grievance, the patient grievance should be resolved or that additional time is requested for investigation and resolution." The hospital failed to follow their own timeframe for the two open grievances.

Based on the review of eight grievance files from July 2018 until October 2018, grievance tracking log, interview with staff, and review of policy and procedures during the survey on 11/8/18, it was found that 5 of 8 reviewed grievances lacked a resolution letter.

Grievances # 1, 2, 4, and 8 lacked resolution letter at the close of investigation. Grievance # 5 had a letter that was sent 30 days after the close of the case. It was reported by the staff assisting with the review that this letter was sent due to persistence of the family to have documentation of investigation. The hospital failed to ensure that all grievance submitters were provided written resolution notices that contained all required elements.

Based on a review of hospital policy, 6 open and 4 closed patient records during the survey on 11/8/18, it was determined that the hospital failed to assess whether patient #5 lacked decision making capacity or certify an incapacity prior to obtaining consents by patient #5's surrogate decision maker.

Per hospital policy titled, "Consent/Refusal to Consent" (04/16) section XI, "The substitute consent may be given only if two physicians, after attempting to consult with the patient regarding the proposed healthcare, certify in writing that the patient is incapable of making an informed decision."

Patient #5 was an 85+ year old who presented to the hospital with multiple medical complaints. Patient was admitted with a gastrointestinal disorder. Per patient's history and physical on admission, patient #5 was "awake, alert, oriented x 3." On the 4th day of admission patient underwent a surgical procedure. Consents for anesthesia and the surgical procedure were signed by the patient's spouse.

There was no mention in the record that patient #5 was unable to make their own decisions nor was a certification of an incapacity performed prior to obtaining consents from a surrogate. Therefore, the hospital failed to honor the patient's right to make informed decisions about their care.