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Based on review of the Hospital Complaint file and interviews, the Hospital failed to ensure that the time frame for review of the grievance and the provision of a response.


Findings included:

1) Review of the Complaint file indicated the written complaint was dated 10/22/09.

A copy of the written response dated 11/25/09, over one month later, was reviewed and noted to be very vague and did not address each of the issues brought forward in the complaint letter.

2) Review of the Hospital policy titled: Patient Complaint and Grievances, section (C) Resolution - indicated that written communication provided on hospital stationary will include: point (e) the written notice will be provided to the patient within 7 days after the initial receipt of the grievance unless otherwise communicated to the patient.

The VP for Patient Care Services and the Chief Nursing Officer [CNO] was interviewed by telephone on 4/15/10 at 10:30 am. The CNO said the first written response was dated 11/25/09 which she acknowledged was not within the hospital's policy for a written response time frame of 7 days. The CNO also acknowledged there were several telephone conversations with the Complainants, but there was no evidence of the discussions or an agreement with the Complainants that the written response would be delayed and this was accepted by the Complainants.

Based on review of the Hospital Complaint file and interviews, the Hospital failed to ensure that in its resolution of the grievance, the hospital must provide the patient with 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.

Findings included:

1) Review of the Complaint file indicated the written complaint was dated 10/22/09.
A copy of the written response dated 11/25/09, over one month later, was reviewed and noted to be very vague and did not address each of the issues brought forward in the complaint letter. The outcome of the investigation indicated that: "I have reviewed our conversation with the nursing leadership and the nursing staff involved, discussing the care and communication as you described it to me." However, there were no action steps or plan of correction mentioned in the letter that addressed each issue raised as a point of concern.

Because dissatisfaction was expressed over the response, a second letter dated 12/17/09 was mailed to the Complainant indicating their right to file additional complaints with the Department of Public Health and the Joint Commission on Accreditation of Health Care Organizations, Office of Quality Monitoring.

Review of the Hospital policy titled: Patient Complaint and Grievances, section (C) Resolution - indicated that written communication provided on hospital stationary will include: point B) the steps taken on behalf of the patient to resolve the grievance C) the result of the grievance process and e) the written notice will be provided to the patient within 7 days after the initial receipt of the grievance unless otherwise communicated to the patient.


2) The VP for Patient Care Services and the Chief Nursing Officer [CNO] was interviewed by telephone on 4/15/10 at 10:30 am.

The CNO said she received another telephone call from the Complainant, no date recalled, informing her the letter was not satisfactory and they agreed to have a meeting. The CNO said the meeting did not occur because a convenient time frame could not be reached for all parties. The CNO said a telephone conversation was held on 12/16/09 where it was communicated that the Complainant wanted to appeal the results and a follow up letter was sent on 12/17/09 as detailed above in the narrative. The CNO said she provided the letter because it was communicated that resolution was not reached.

The CNO acknowledged the written response letter was non-specific and did not include steps taken to address each issue and a plan of correction for each item.

Based on direct observations during the survey on 4/12/10 in which three attempts to open the ICU double wooden door were successful, review of the Hospital work order for the door dated 1/7/09 and interviews, the Hospital failed to ensure the condition of the physical plant and the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients were assured.

Findings included:

1) The Complainant was interviewed on 4/8/10 by telephone at 3:35 pm. The Complainant was concerned about the overall security of the ICU. The Complainant said that one of the locked doors to the ICU was not locking properly and allowed anyone to walk straight in, unquestioned. The Complainant was particularly concerned one night because one female visitor arrived in a suspected inebriated state and tried to open the door that did happen to lock. The woman then entered the waiting area and asked them where the Emergency Department was and left the area. The Complainant said that Security was very important to the Family and they had asked about it prior to the Patient being transferred and they were assured the facility was safe and secure. The Complainant said the Nurse Manager admitted there was a problem with the ICU door during the time frame of 9/13 and 14/09 and that it would be fixed.

2) A tour of the Intensive Care Unit [ICU] was conducted on 4/12/10 at 8:50 am shortly after arrival to the Hospital with the Vice President for Medical Affairs. The ICU entrance was observed to have three distinct doorways: To the Left - two double wooden doors that opened outward and were labeled as "locked" with directions to call on the nearby telephone to request entry and then staff would buzz them open for entry into the ICU. To the Center - was a large sliding glass door system that required a card swipe that hospital staff used for entry. To the Right - was a glass door to the family waiting area that was open to the public. Signage indicated the ICU was locked and the public was to use the phone on the wall to gain entry into the ICU.

3) This Surveyor turned the knob of the double wooden door entry and it opened without having to call the ICU staff members to unlock the door. The Vice President for Medical Affairs [VPMA] then entered the ICU and opened the double wooden doors from the inside by pressing the button and it was observed that the open doors now would not close. The VPMA then shut the door manually and we again attempted to open the door: it now would not open.

On leaving the ICU setting after the tour, this Surveyor again attempted to open the double wooden doors to the left. At this Surveyor's turn of the knob, the door again opened. The VPME said it was because the door was not completely shut, so we shut the door and then attempted to open it again. It was noted to be locked after this attempt. This Surveyor said the door did not consistently lock and that repeated attempts to correctly close the door to prevent it from opening were not satisfactory. The observations included two successful attempts to open the double wooden doors from the outside and/or direct observations the door did not shut from the inside of the ICU after pushing the round button to open it. The double wooden entrance door to the Left of the ICU was not functioning properly.

At noon, the VPME reported he independently attempted to open the wooden double doors again and it was not locked.

4) The work order for the ICU double wooden doors dated 1/7/10 by the Hospital's contracted Security Contract indicated the request was made for repair of the exit devices and completed.

5) During the tour of the ICU conducted on 5/12/10, the double wooden doors to the ICU were still not consistently locked to ensure patient and clinical staff safety and security, approximately 8 months after the complaint was initially filed with the Hospital.