HospitalInspections.org

Based on document review and interview, the facility failed to ensure, complaint/grievance answered in a timely manner in one instance.

Findings include:

1. Review of facility policy, Complaint/Grievance Management, last approved 01/2017, indicated the following. If a complaint cannot be resolved promptly by staff present, or is referred to unit management, the complainant should receive a written response within seven (7) days.

2. Review of facility email indicated case #18889 (complaint) was received on or before 1/30/2019 and answered 02/13/2020.

3. Interview with N2 (Quality Director) on 2/17/2020, at approximately 1333 hours, confirmed complaint #18889 was not answered in 7 days.

Based on document review and interview, the facility failed to ensure evaluation of care provided for 9 of 9 patients medical records (MRs) reviewed (patients 1, 2, 3, 4, 5, 6, 7, 8 and 9's MR).

Findings include:

1. Review of facility, Associate Guidelines and Expectations, updated 05/01/2018 indicated the following. Hourly rounding completed every hour from 0600-2200 (hours), every two hours from 2200-0600 (hours) daily.

2. Patient 1, 2, 3, 4, 5, 6, 7, 8, and 9's MR lacked rounding completed every hour from 0600-2200 (hours) or every two hours from 2200-0600 (hours) during admission.
Patient 1's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 01/09/2020, 1600 until 2020 (hours).
Patient 2's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 12/31/2019 from 0050-0400 (hours).
Patient 3's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 01/04/2020, 0800-1115 (hours).
Patient 4's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 12/31/2019, 0430-0813 (hours).
Patient 5's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 12/30/2019, 1049-1308 (hours).
Patient 6's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 12/30/2019, 1253-1453 hours.
Patient 7's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 01/02/2020, 0033-0314 (hours).
Patient 8's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 12/31/2019, 0437-0730 hours.
Patient 9's MR lacked rounding every hour from 0600-2200 (hours) and/or every two hours from 2200-0600 (hours) including but not limited to 01/04/2020, 0055-0341 (hours).

3. Interview on 2/17/2020, at approximately 1405 hours, with N7 (Clinical Informatics) confirmed patient's MR reviewed 1 through 9 MR had lack of documentation in rounding (every hour and/or every 2 hours).