HospitalInspections.org

Based on interview and record review, the facility did not provide a written response to 1 of 1 patient (Patient #1) who lodged a complaint to Personnel #2 on January 9, 2010 as required by their policy.

Findings included:

In an interview on 02/16/11 at 1:15 PM, Personnel #2 was asked if he received a complaint from Patient #1. Personnel #2 replied that he did on "January 8th or 9th." Personnel #2 stated he informed the patient that her complaint will be referred to the clinical director since this was a "clinical" matter as well as administrative. Personnel #2 was asked if there was a record of this complaint and if they followed their "Complaint Resolution" process. He replied that he did not document this complaint and that there was no written response provided to Patient #1.

The "Hospital...Manual Complaint Resolution" revised 08/2006 required "The Administrator or their designee will...provide follow-up to the patient within seven days..."

Based on interview and record review, the facility did not accurately record the time of the "Time Out" procedure conducted in the OR (operating room) for 2 of 3 patients (Patient #1, #2, & #3) who underwent pain management procedures for the month of November 2010.

(Note: "Time Out" is a method of "verifying the patient, procedure, site & consent with the team" prior to start of procedure.)

Findings included:

Patient #1 was admitted on 11/23/10 for "Cervical epidural steroid injection Right C6-7 and Thoracic facet injection Left T6-7, T7-8." The "start time" of the procedure was recorded at 3:09 PM. The "Time Out" was conducted at 3:11 PM, 2 minutes after the procedure started.

Patient #2 was admitted on 11/11/10 for "Cervical epidural steroid injection midline C4-5 and Cervical facet injection bilateral C4-5, C5-6, C6-7." The "start time" of the procedure was recorded at 10:50 AM. The "Time Out" was conducted at 10:52 AM, 2 minutes after the procedure started.

In an interview on 02/16/11 at 10:25 AM, Personnel #3 was asked why the " time-out " was performed 2 minutes after the procedure started. She explained that they perform electronic documentation in the OR. " The nurse has to open 2 programs to document the time-out and it takes about 2 minutes to complete it. "

The "Clinical Manual Universal Protocol" revised 02/2011 required "Time-out is conducted prior to starting the procedure..."

The "...Health Information Management Documentation and Flow of the Medical Record" revised 06/2009 required "The medical record will provide adequate and accurate documentation..."