HospitalInspections.org

Based on interview and record review, the hospital failed to provide in writing its resolution of the complaint/grievance for 1 of 2 patients (Patient #2) who filed a complaint to the hospital on 10/1/15.

Findings included:

Personnel #2 received Patient #2's complaint on 9/16/15 via email notification.

In an interview on 11/5/15 at 9:50 AM, Personnel #2 confirmed that a response letter to the above complaint was not sent.

Policy # ADMIN06 revised 1/2013 required "In resolution of the grievance, a written notice of the decision must be provided to the complainant..."

Based on interview and record review, the hospital's registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 1 patient (Patient #2) who presented in the emergency department (ED) on 9/15/15. The nursing staff did not offer toileting opportunities to Patient #2 who was 90 years old and had history of dementia.

Findings included:

Patient #2 presented in the ED on 9/15/15 at 9:21 AM with a chief complaint of falling from a chair. The patient was discharged at 9:21 PM with a diagnosis of "fall without injury." From the time the patient presented in the ED and to the time he was discharged (12 hours), there was no documentation that the patient was offered toileting opportunities and/or if his disposable brief was changed.

In an interview on 11/5/15 at 9:50 AM, Personnel #2 confirmed the above findings.

Policy #ED71 "ED Standards for Documentation...and Reassessments" revised 1/2014 required "B. Documentation of reassessment...should reflect...any interventions performed...F. reassessments should occur...or done at a minimum...every 4 hours or more..."