HospitalInspections.org

Based on facility policy review and interview, it was determined that the facility did not specify time frames for review of grievances and the provision of a response.

Findings include:


A review of the facility "Patient Complaint" policy was completed on 12/14/2010. The policy indicated,
"...All patient complaints regarding treatment, service, damaged/lost articles or billing will be forwarded to the Department Manager for investigation, followed by appropriate and timely response...will follow up on all patient complaints insuring that all documentation is complete and that the patient has been provided timely feedback regarding their complaint."

An interview was held with the facility risk manager on 12/14/2010. She stated that she was the person responsible for responding to patient complaints. She stated that she was not aware that there needed to be specific time frames designated in the policy. She stated that she tried to address the complaints within 48 hours of receiving them.

Based on facility policy review and interview, it was determined that the facility did not always provide the complainant with written notice of its decision.

Findings include:


A review of the facility "Patient Complaint" policy was completed on 12/14/2010. The policy did not indicate that the complainant would be notified in witting of the decision regarding the complaint.

An interview was held with the facility risk manager on 12/14/2010. She stated that complaints are documented on a "Customer Complaint Form" and the form is then given to the appropriate department manager to investigate. She stated that most of the communication with the complainant is verbal in person or by telephone.

Based on observation and interview it was determined that the hospital did not adequately maintain all equipment to ensure safety and quality. Specifically, the hospital did not routinely check all operating room (OR) equipment to determine it could be properly sanitized.

Findings include:

On the afternoon of 12/13/10 between 2:30 PM and 4:10 PM, the hospital's OR area was observed.

1. The Formica desks in OR 2 and OR 3 were observed. On both ends of each desk there was bare wood exposed and cracked and missing formica at the corners that rendered these areas unsanitizable.
2. The Bovie stands in OR 2 and OR 3 were observed to be rusty in numerous places that rendered these areas unsanitizable.
3. The vinyl OR patient table pads in OR 2 and OR 3 were found to have numerous cracks in the vinyl that rendered these areas/ the pads unsanitizable.

The afternoon of 12/13/10, the OR Manager was interviewed. She stated that she had not thought about the formica on the desks as being unsanitizable, nor had she thought about the Bovie stands as presenting an problem and stated that some of the patient OR pads had been replaced but didn't realize that more pads needed replacing.

Based on interview and observation it was determined that the hospital did not always maintain high standards of medical practice and patient care. Specifically, the hospital did not have a method to trace reprocessed medical devices to the patients they were used on during surgery.

Findings include:

On the morning of 12/14/10, the Director of Nursing (DON), the OR Manager and an OR technician in charge of sterilizing medical equipment were interviewed. They stated that they were not able to trace reprocessed medical equipment to the patient on whom it was used during surgery. They also stated that they adhered to the Association for the Advancement of Medical Instrumentation (AAMI) standards.

The following was documented in the AAMI, "Comprehensive guide to steam sterilization and sterility assurance in health care facilities" copyright 2006 page 79, "Ideally, every reprocessed medical devise ...should be fully traceable to the patient on whom it is used ...; such traceability can be accomplished by recording the sterilizer load identifier on the patient chart or the patient name on the load record."

17494

Based on review of the operating room (OR) registry it was determined that it was not complete.

Findings include:

On the morning of 12/14/10 the OR registry was reviewed. The OR registry did not have the post operative diagnosis documented for each patient. The OR manager was asked about the listing of the post operative diagnosis and stated that it was not part of their registry.