HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to follow regulatory requirements and its own grievance policy by failing to provide the patient or patient representative with written notice of its decision with all required components for 1 of 4 patient grievances reviewed [Patient #1].

Findings were:

Despite several verbal and written complaints made on behalf of Patient #1, the facility provided no information to the patient or complainant regarding steps taken on behalf of the patient to investigate these complaints or any results of the investigations.

Facility policy #PR-005 entitled Patient/Family Complaint and Grievance Process, effective 3/2014, included the following:
" Purpose: ...
To establish procedures in which conflicts/complaints/grievances are handled in an appropriate and timely manner ...
Definitions:
Grievance - A patient care complaint not resolved promptly by staff available, or a patient care complaint presented to the hospital post discharge ...
2. Urgent concerns regarding quality of care or premature discharge will be referred to the Director of Quality Management as received ...
5. The Quality Council, as delegated by the Board of Trustees, will be responsible for the effective operation of the complaint/grievance process ...

2. Efforts will be made to complete an investigation and resolve the grievance within ten (10) working days of receipt of the grievance. The Patient Liaison to log, track and route to the appropriate Departments for review ...
4. Department Director(s)/Unit Manager(s)/Supervisor(s) will attempt to take appropriate action to resolve the grievance ...
Resolution Committee
1. The Resolution Committee is responsible for the oversight of the complaint/grievance process. Complaints/grievances will be reviewed at the Resolution Committee meeting twice a month ...
2. The Patient Liaison or other designee from the Resolution Committee will provide to the patient/complainant written notice of its decision regarding the substance of each grievance that contains the name of a hospital contact, steps taken to investigate, and the date of completion. This notice will be sent to the complainant/patient as soon as possible after a determination has been made ..."

A review of email communication to Staff #4, Med-Surg Nursing Director of the 3rd and 4th floors, from Staff #10, Patient Liaison, revealed the following:

Sent on 9/4/15 at 4:02 p.m.:
"[Wife of Patient #1] was very upset about a nurse on the fourth floor whom was in room 462. She was in tears and could hardly talk about it without crying and getting very upset she stated that the nurse was rough and rude with her husband. I provided her with a formal complaint form and assured her that a manager would be getting in touch with her about her concerns. I told her she could turn the form over to the charge nurse in ICU and we would be forwarding it to the appropriate manager."

Sent on 9/7/15 at 10:52 a.m.:
"[Patient #1] is now in room 384 I don't know if they turned in the formal complaint on Friday I asked [RN] if she had one and did not at this point but they may have turned it in to [another individual]. However, [wife of Patient #1] did want to speak to a manager if possible when I last spoke to her on Friday."

An email to Staff #10 from Staff #4 on 9/4/15 at 4:06 p.m., included the following:
"Is she ok with a Tuesday response or should the charge go up there?"

No further email communication regarding this matter was made available for surveyor review. Staff #4 stated this was all the email communication she had regarding the matter.

Patient Complaint Documentation Form

A review of a Patient Complaint Documentation Form, ID#12029, on 10/14/15 included the following:
"[Wife of Patient #1] - dischg 9/7 - called me and stated:
He was in ICU and that was great. 4th floor terrible - nurse told everyone he pulled out IV and just left it there. I told them to never give him more than 1 Tylenol because his heart is too weak and [RN, Staff #5] gave him 2 and he almost didn't wake up. Next night nurse gave him sleeping pill and shot - he was ice cold - nearly died.

On the third floor (384) the nurse didn't put up the rail - they didn't give him any help with his food. I took him to the BR (bathroom) and he accidentally pulled the cord but no one came. I put depends on him that I brought from home. The next day he was still in the same ones ...The nurses on 3 just played with their hair and texted and acted bored - didn't look up when I walked up - didn't wait on the pts. Did nothing for him so I took him out AMA.

(I asked how he is now) He's doing good - was home 2 days then I took him to HH (he was there 9/9-9/17). That's what you get when you overdose - won't ever come to SAMC again ...Just walk on the 3rd floor some evening and see - no one is doing anything ...

If he had died you'd hear a lot more from me. Check on this cause it's bad.

She said there was nothing else - just wanted us to know this ..."

In an interview with Staff #4, Nursing Director, Medical-Surgical 3rd and 4th floors, on the morning of 1/26/16 in a facility office, when asked about whether there had been a complaint that she knew of regarding this patient, she stated, "We heard that [the wife of Patient #1] was upset, but by the time we came to address it, they'd left AMA. Another manager did a brief chart review, but then she reported to me that there were no issues."

In an interview with Staff #9, Special Projects Director/Patient Liaison, on the morning of 1/26/16 in a facility office, she stated, "[The wife of Patient #1] called me directly in October. She was obviously upset about the care and we had a fairly long conversation. I tried to transcribe exactly what she was telling me ...When we got to the end of the conversation, I asked her if there was anything else and she said no, she just wanted us to know about this. She didn't ask for any kind of response or result. And quite frankly, we wouldn't supply the results of any kind of investigation we ever did here to a patient. That's our own internal process. If we send a letter, it's just that we received they're complaint and have followed up with it appropriately. Sometimes I'll send a letter if they've indicated they want one."

In an interview with Staff #1, Quality Management, on the morning of 1/26/16, in a facility office, she stated, "We don't automatically supply a written response to patient complaints. From what I understood, [the wife of Patient #1] said she just wanted us to know about the issues." Upon review of the documentation of interactions of staff with [the wife of Patient #1] and her complaints, she stated, "Yes, this sounds like a grievance and should have had more thorough follow-up."

The above findings were again confirmed in an interview with the Quality Manager and other administrative staff on the morning of 1/27/16 in a facility office during the exit conference.

Based on a review of facility documentation and staff interviews, nursing services failed to document on an ongoing basis the hygiene and linen care provided in 2 of 4 patient records reviewed [Patients #1 and #4] per hospital policy and accepted standards of nursing practice.

Findings were:

Facility policy #PA-002 entitled Patient Assessment and Reassessment, effective 3/2014, included the following:
"B. For in-patient units, a system assessment is completed by the RN every shift ...
PCTs, LVNs may assist in collection of vital signs, height, weight, intake and output, including characteristics ...
Medical Surgical Nursing Units:
Reassessment
- Every shift ...
- Patient care needs ... "

In an interview with Staff #4, Nursing Director, Medical-Surgical 3rd and 4th floors, on the morning of 1/26/16 in a facility office, she stated, "I can't find where there's much documentation of patient care [for Patient #1]. There's a stand-alone screen where nurses are supposed to document, where they should document, bath, linen care, and special baths - personal care stuff. I don't really see any of that in this chart. Only one nurse on one shift completed it ..."

Additional patient records were reviewed on the morning of 1/27/16. Upon review of the medical record of Patient #4, she agreed only one RN consistently documented these items.

These findings were again confirmed in an exit interview with the Quality Manager and other administrative staff on the morning of 1/27/16 in a facility office.