HospitalInspections.org

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Based on interview and record review it was determined the hospital failed to implement the hospital grievance policy and procedure regarding a complaint about the care of Patient 5. Findings include:

During the survey the medical record for Patient 5 was reviewed in detail. That review revealed that Patient 5 had multiple admissions to the hospital during the month of August, 2010. According to hospital records she had been an in-patient on 8/5 and 8/6/10, and again on 8/22 through 8/26/10.

In interview on 8/24/10, Witness A indicated that during the hospital stay on 8/6, Patient 5 had a "rough and painful" experience during the administration of an enema. Witness A further stated that while Patient 5 was in the hospital on 8/23/10, Witness A had expressed a complaint to "Linda" the "house supervisor" regarding the enema procedure during the 8/6/10 stay.

Reportedly, the house supervisor referred the complaint to the unit manager, Witness E4. In interview on 9/13/10 Witness E4 acknowledged that on 8/23/10 they had received a written summary of a complaint regarding Patient 5's previous care. Witness E4 reports that they discussed the incident with Witness A, Patient 5, Witness E5, and others. Witness E4 then forwarded an "incident report" to Witness E9 in Patient Relations.

Review of hospital policies and procedures determined the hospital had a specific policy "Patient Complaint Management and Documentation" that defined a complaint and/or grievance. That policy outlined the procedures to be used in response to a grievance, "Patient Relations-Grievance Procedure." Interview and record review determined policy "Patient Complaint Management and Documentation" had not been implemented following the 8/23 complaint regarding Patient 5's care on 8/6/10.

According to hospital policy "a post-hospital verbal communication regarding patient care..." is a complaint. Also by policy a "complaint that requires review and/or further action for resolution" is a grievance. Once a complaint is considered a grievance "the Patient Relations Representative will acknowledge the grievance "either verbally (within 48 hours) or in writing (within 7 days)..."

Those procedures were not implemented in response to the complaint regarding Patient 5's care on 8/6/10. Neither Witness A or Patient 5 received verbal or written acknowledgement that a grievance had been received or that an investigation would be completed.

In interview on 9/13/10 Witness E10 acknowledged that such communication had not occurred. The hospital failed to implement hospital procedures following the receipt of a complaint regarding Patient 5's care.

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