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Based on record review and interview the facility's Complaint Coordinator failed to provide evidence that patient # 1 ' s complaint regarding inadequacy of the air mattress to cushion his pressure sores was investigated and that measures were taken to resolve the issue; The facility failed to inform the patient in writing of actions the facility took to resolve his concerns. (One patient)

Findings:

Review of complaint narrative revealed allegations that Patient # 1 was bed bound and had pressure ulcers on his sacrum. The patient complained he was not satisfied with his wound management.The air mattress he was on during his two weeks hospital stay, did not function adequately.

During a telephone interview on 1/12/2010 at 9 am with Patient # 1 he stated his needs for a functional air mattress to relieve pressure on his ulcers were not met by staff on the unit resulting in the deterioration of his ulcer.

According to Patient # 1 when unit staffs were not helping with his concerns, he requested a visit from the patient relations personnel to discuss his concerns but did not get a visit.

Patient # 1 stated no one at the hospital contacted him regarding the concerns he had during his hospital stay.

Review of Patient # 1 ' s clinical record revealed documentation dated 9/24/09 that the patient was a Paraplegic admitted to the hospital with diagnoses of Stage four (4) sacral decubitus ulcers, Diabetes and Urinary Tract Infection.

Review of Physician ' s orders dated 9/24/09 revealed orders for strict bed rest. There were orders dated 9/25/09 for low air loss mattress with over head trapeze.

Review of Nurses notes dated 9/25/09 revealed documention that the mattress was implemented.

Further review of the nurses ' notes dated 9/25/09, revealed documentation that "Patient said he was informed he had a skin tear, said he was going to sue the facility" There was no further information regarding the issue.

Review of Nurses notes dated 9/27/09 revealed documentation that "patient said he was informed he had a skin tear, said he was going to sue the facility." There was no further information regarding the issue.

Review of the facility's complaint log for September 2009 revealed documentation that Patient # 1 made telephone complaints to the Patient Relations Department on 9/29/09 regarding skin tears he was getting from the tapes the nurses used during dressing changes .The patient stated his skin problems started months ago with the Urology department at the hospital.

There was documentation that Patient # 1 called Patient Relations Department on 10/2/09 stating the facility was " killing him " and he wanted to go home and continue taking his medications there.

There was documentation on the log that the Patient Relations Department redirected the complaint to the Unit Manager for resolution along with an attached complaint resolution form.

There was no information on the patient ' s clinical record or the Complaint log indicating the outcome of the complaint .There was no evidence that an investigation was done and a written response was sent to the complainant.

During an interview on 1/13/2010 at 11:15 am with Staff # 50 ,he stated the Patient ' s concerns were not classified as a grievance but as a complaint and per the facility ' s protocol was redirected to the unit manager where the patient was located to be resolved.

Staff # 50 stated a follow up with the unit manager was not conducted because it was a complaint and not a grievance.

Staff # 50 stated he realized there was a problem with how complaints were currently categorized and handled, and new systems would be implemented. He further stated there was no written response to the patient.

During an interview on 1/13/2010 at 11:40 am with Staffs # 51 she stated the patient had complaints regarding several care issues.

According to Staff # 51 the patient was not satisfied with the Air mattress that was ordered for him because it was nota good and the air kept leaking out of the mattress.
According to Staff # 51 there was no documentation regarding a resolution of the complaints.

Review of the facility ' s policy/procedure on Grievance revised 3/30/06 documented the following information:

" If a verbal complaint is initially made to the Patient/ Customer Relations Department, a complaint Notification Memo (Appendix D) and the complaint will be forwarded to the involved department for resolution.

Based on record review and interview the facility's Complaint Coordinator failed to provide evidence that patient # 1 ' s complaint regarding inadequacy of the air mattress to cushion his pressure sores was investigated and that measures were taken to resolve the issue; The facility failed to inform the patient in writing of actions the facility took to resolve his concerns. (One patient)

Findings:

Review of complaint narrative revealed allegations that Patient # 1 was bed bound and had pressure ulcers on his sacrum. The patient complained he was not satisfied with his wound management.The air mattress he was on during his two weeks hospital stay, did not function adequately.

During a telephone interview on 1/12/2010 at 9 am with Patient # 1 he stated his needs for a functional air mattress to relieve pressure on his ulcers were not met by staff on the unit resulting in the deterioration of his ulcer.

According to Patient # 1 when unit staffs were not helping with his concerns, he requested a visit from the patient relations personnel to discuss his concerns but did not get a visit.

Patient # 1 stated no one at the hospital contacted him regarding the concerns he had during his hospital stay.

Review of Patient # 1 ' s clinical record revealed documentation dated 9/24/09 that the patient was a Paraplegic admitted to the hospital with diagnoses of Stage four (4) sacral decubitus ulcers, Diabetes and Urinary Tract Infection.

Review of Physician ' s orders dated 9/24/09 revealed orders for strict bed rest. There were orders dated 9/25/09 for low air loss mattress with over head trapeze.

Review of Nurses notes dated 9/25/09 revealed documention that the mattress was implemented.

Further review of the nurses ' notes dated 9/25/09, revealed documentation that "Patient said he was informed he had a skin tear, said he was going to sue the facility" There was no further information regarding the issue.

Review of Nurses notes dated 9/27/09 revealed documentation that "patient said he was informed he had a skin tear, said he was going to sue the facility." There was no further information regarding the issue.

Review of the facility's complaint log for September 2009 revealed documentation that Patient # 1 made telephone complaints to the Patient Relations Department on 9/29/09 regarding skin tears he was getting from the tapes the nurses used during dressing changes .The patient stated his skin problems started months ago with the Urology department at the hospital.

There was documentation that Patient # 1 called Patient Relations Department on 10/2/09 stating the facility was " killing him " and he wanted to go home and continue taking his medications there.

There was documentation on the log that the Patient Relations Department redirected the complaint to the Unit Manager for resolution along with an attached complaint resolution form.

There was no information on the patient ' s clinical record or the Complaint log indicating the outcome of the complaint .There was no evidence that an investigation was done and a written response was sent to the complainant.

During an interview on 1/13/2010 at 11:15 am with Staff # 50 ,he stated the Patient ' s concerns were not classified as a grievance but as a complaint and per the facility ' s protocol was redirected to the unit manager where the patient was located to be resolved.

Staff # 50 stated a follow up with the unit manager was not conducted because it was a complaint and not a grievance.

Staff # 50 stated he realized there was a problem with how complaints were currently categorized and handled, and new systems would be implemented. He further stated there was no written response to the patient.

During an interview on 1/13/2010 at 11:40 am with Staffs # 51 she stated the patient had complaints regarding several care issues.

According to Staff # 51 the patient was not satisfied with the Air mattress that was ordered for him because it was nota good and the air kept leaking out of the mattress.
According to Staff # 51 there was no documentation regarding a resolution of the complaints.

Review of the facility ' s policy/procedure on Grievance revised 3/30/06 documented the following information:

" If a verbal complaint is initially made to the Patient/ Customer Relations Department, a complaint Notification Memo (Appendix D) and the complaint will be forwarded to the involved department for resolution.