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Based on record review and interview the hospital failed to ensure the process for resolving grievances included a documented investigation to determine if the incident listed in the grievance had occurred and/or the root cause of any quality issues identified in the investigation for 3 of 3 grievances reviewed (#5, #10, #R1). Findings:

Patient #5
Review of the e-mail dated 03/23/10 at 5:14pm from the Complainant Patient #5 indicated she had been brought to the hospital and sat for hours with three people in the waiting area. Further she indicated the staff were laughing at her and saying there was nothing wrong with her even though her knee was the size of two grapefruits and she had not been seen by the doctor. Patient #5 indicated that she had been out dancing and may have had " one drink too many " but was not drunk. Further after she was told nothing was broken she had to ask for something to walk with because she still could not put pressure on her leg. An air cast was brought to the room and she was told to put it on herself. The staff then told her to get off the table and try to walk to the bathroom. At this point she indicated the bed was not locked and she fell and no one would help her up. The complainant indicated she started crying and the nursing staff told her to " get over it " . She asked for her friend so she could help her get dressed because the staff kept telling her she needed to leave. Further she indicated no one offered her a wheelchair or to help her get a ride home. In addition the hospital had lost her ID which made it necessary for her husband to overnight her passport to her in order to be able to fly home. The complainant indicated her husband received it " post dated the 14th from your hospital " in the mail. Further she indicated she wanted all the charges for the ED visit removed because she was not paying for all of the mistakes the hospital made and gave them until Friday to respond. Patient #5 indicated if the hospital could not make a decision, she would take this matter to " her lawyer, the media and much beyond " .

Review of Grievance Entry Log #410 for Patient #5 revealed the hospital had received an e-mail (Grievance) concerning her Emergency Department visit on 03/14/10. Further review revealed she was extremely upset about the way she was treated and misdiagnosed by the physician and requested someone from the hospital to call her because she wanted her bill " written off " . The complaint informed the hospital she had witnesses to the mistreatment and that her friend videoed the staff making comments about her. In addition she had discussed the matter with an attorney.

Review of the letter dated 03/24/10 addressed to Patient #5 submitted to the hospital revealed the hospital acknowledged receipt of her letter and would review and respond. Also included in the letter was the number where the Patient Advocate, S7 could be reached.

In a face to face interview on 05/11/10 at 11:15am S7, Patient Advocate indicated when he receives a grievance, he inputs the information into the database and then routes to the applicable department head/manager for investigation. In regards to the e-mail he received from Patient #5, S7 indicated he routed it to the S4 ED Medical Director and S6 Assistant Nursing Administrator to investigate since it involved both physicians and nursing staff.

Review of the e-mail from MD S4 ED Medical Director to S7 Patient Advocate dated/timed 03/25/10 at 8:52am revealed that S4 had spoken with Patient #5 and had apologized for the challenges she faced in the ED. Further he indicated Patient #5 informed him she was not interested in apologies but rather compensation and wanted to talk only to a decision maker who " was going to write off her bill and compensate her for the complications she had suffered. Further she refused to share any other information with S4 because he was not a decision maker.

In a face to face interview on 05/12/10 at 8:30am S21 the Director of Performance, after review of the Grievance policy and the documentation of the investigation of the grievance submitted by Patient #5, indicated there had been a breakdown in the process. Further S21 indicated the information had not been communicated to all staff members who needed to be involved in order to make a decision and implement corrective actions.

In a face to face interview on 05/12/10 at 9:10am MD S4 ED Medical Director indicated he had called Patient #5 as he does with all complaints concerning the emergency room relating to physician matters; however she did not want to talk to him because he could not tell her that the charges for the care provided would be removed from her bill. Further S4 indicated he talked to all physicians involved and reviewed Patient #5 ' s medical record. MD S4 indicated he again attempted to speak to her but she told him she did not want to talk to him because he was not a decision-maker.

In a face to face interview on 05/12/10 at 11:15am S6 Assistant Nursing Administrator indicated she delegated the investigation of the grievance for Patient #5 to RN Supervisor S30.

In a face to face interview on 05/12/10 at 12:50pm RN Supervisor S30 indicated he had talked to the staff who had been on duty the night Patient #5 was in the ED; however he had not written anything down nor could he remember the specific question asked in regard to Patient #5 ' s care.

Review of Grievance Entry Log #410 for Patient #5 revealed the case was closed on 03/29/10.

The hospital could present no further documentation of an investigation or communication with Patient #5 according to the hospital ' s policy and procedure for Grievances.

Review of the Grievance Policy revealed that a resolution to a patient grievance must be completed within 30 calendar days. Further review revealed a written notification must be sent to the complainant detailing the steps taken to investigate the issue, the resolution, the date the issue was resolved and the telephone number of a staff member who can be contacted.

Patient #10:
Review of the hospital grievance log and Patient # 10's grievance file revealed Patient #10 filed a grievance on 3/17/2010 regarding Physician #S14 screaming at her and an unidentified male physician ripping her IV (Intravenous) line out.

Review of Patient #10's grievance file revealed no documented evidence of an investigation of this grievance to include no documentation of interviews with staff (physicians and nurses) in an attempt to determine if any opportunities for quality improvement existed and their root cause.

During a face to face interview on 5/12/2010 at 9:05 a.m., Emergency Department Medical Director, Physician S4, indicated it had not been his practice to document his investigation into grievances. Physician S4 indicated he would interview physicians involved in incidents where grievances had been initiated; however, he would not document these interviews or investigations. S4 indicated (confirmed with e-mail review) that he had notified Emergency Department staff of an increase in patient complaints regarding staff behavior and the need for all staff to be mindful of patients rights while in the Emergency Department.


Patient #R1:
Review of the hospital grievance log and Patient #R1's grievance file revealed Patient #R1's family filed a grievance on 3/24/2010 alleging money had been missing from his wallet when the wallet was returned to him by hospital police. The family claimed Patient #R1 had $50.00 (fifty dollars) in his wallet at the time the wallet was collected by hospital police during his hospital admission and upon return there was only $25.00 (twenty five dollars) in his wallet.

Further review of the grievance file for Patient #R1 revealed no documented evidence of an investigation of this grievance.

Review of the "Valuables Envelope" for Patient #R1 dated 2/18/2010 revealed the following logged items: (1) cell phone, (1) cell phone charger, (1) Black Wallet, (1) LADL (Louisiana Driver ' s License), (1) SS (social security) card, Misc (miscellaneous) papers, (1) pair of glasses, (1) glass case. Further review revealed a "Valuables Claim Check" with items listed as "LA (Louisiana) Purchase Card, (4) $5.00 (four five dollar bills), (5) $1.00 (five one dollar bills)." Review revealed this " Valuables Claim Check " to have the signature of one Police Officer.

During a telephone interview on 5/11/10 at 3:30 p.m., Sergeant S36 indicated the Police Officer that signed the Valuables Envelope without a witness no longer worked at the hospital due to being out on FEMLA (Family Emergency Medical Leave Act) leave.

Review of the entire Grievance File revealed no documented evidence of an investigation regarding the allegation that money had been missing from Patient #R1's wallet and no documented evidence of an investigation as to why hospital policy requiring two employees's signatures on the "Valuables Envelope" had not been followed. This finding was confirmed by Patient Advocate S7 on 5/11/2010 at 11:25 a.m. who further indicated he did not investigate further because the valuables envelope containing all the items that were listed on the envelope had been returned to the patient (the grievance indicated there had been fifty dollars in the patient's wallet rather than the logged twenty five dollars and only one signature was noted on the envelope).

Review of the hospital policy titled, "Securing Patients' Personal Property, dated 11/30/2009" presented by the hospital as their current policy revealed in part, "Patient Care Services' staff shall inventory and record patients personal property on a Patient Clothes and Valuables form in the presence and under the observation of a Hospital Police Officer. To verify and confirm the inventory of patients' personal property, the Patients' Clothes and Valuables form shall be signed by the Patient Care Services staff member who inventoried and recorded the patient's personal property and the Hospital Police Officer who observed the process."

Based on record review and interview the hospital failed to ensure in the resolution of grievances that the patient/patient's representative was provided a written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 3 of 3 grievances reviewed (#5, #10, #R1). Findings:

Patient #5
Review of Grievance Entry Log #410 for Patient #5 revealed the hospital had received an e-mail (Grievance) concerning her Emergency Department visit on 03/14/10. Further review revealed she was extremely upset about the way she was treated and misdiagnosed by the physician and requested someone from the hospital to call her because she wanted her bill " written off " . The complaint informed the hospital she had witnesses to the mistreatment and that her friend videoed the staff making comments about her. In addition she had discussed the matter with an attorney.

Review of the letter dated 03/24/10 addressed to Patient #5 submitted to the hospital revealed the hospital acknowledged receipt of her e-mail dated 03/24/10 and would review and respond. Also included in the letter was the number where the Patient Advocate, S7 could be reached.

In a face to face interview on 05/11/10 at 11:15am S7, Patient Advocate indicated when he receives a grievance, he inputs the information into the database and then routes to the applicable department head/manager for investigation. In regards to the e-mail he received from Patient #5, S7 indicated he routed it to the S4 ED Medical Director and S6 Assistant Nursing Administrator S6 to investigate since it involved both physicians and nursing staff.

Review of Grievance Entry Log #410 for Patient #5 revealed the case was closed on 03/29/10.

The hospital could present no further documentation of an investigation or communication with Patient #5 according to the hospital ' s policy and procedure for Grievances.

In a face to face interview on 05/12/10 at 8:30am S21 the Director of Performance, after review of the Grievance policy and the documentation of the investigation of the grievance submitted by Patient #5, indicated there had been a breakdown in the process. Further S21 indicated the information had not been communicated to all staff members who needed to be involved in order to make a decision and implement corrective actions.


Patient #R1:
Review of the hospital grievance log and Patient #R1's grievance file revealed Patient #R1's family filed a grievance on 3/24/2010 regarding money missing from his wallet when returned to him by hospital police. The family claimed Patient #R1 had $50.00 (fifty dollars) in his wallet at the time the wallet was collected by hospital police and upon return there was only $25.00 (twenty five dollars) in his wallet.

Further review of the grievance file for Patient #R1 revealed no documented evidence of a written notice being provided to Patient #R1 or his family regarding the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This finding was confirmed by Patient Advocate S7 on 5/11/2010 at 3:15 p.m. who further indicated he did not think a follow up letter was needed because the patient's wallet with contents listed on the envelope had been returned to the patient. Grievance file review revealed no documented evidence of an investigation into the allegation of missing money when the wallet was returned from a valuables envelope with no witness signature at the time the valuables were collected.

Patient #10:
Review of the hospital grievance log and Patient # 10's grievance file revealed Patient #10 filed a grievance on 3/17/2010 regarding Physician #S14 screaming at her and an unidentified male physician ripping her IV (Intravenous) line out.

Review of Patient #10's grievance file revealed a form letter that was sent to Patient #10 on 3/22/2010. Further review of this letter revealed no documented evidence of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, or the date of completion. This finding was confirmed by Patient Advocate S7 on 5/11/2010 at 11:25 a.m. who further indicated his practice had been to use a modified form letter prepared by Risk Management for all patients who filed grievances. Patient Advocate S7 also confirmed the letter did not contain the steps taken on behalf of the patient to investigate the grievance or the results of the investigation.

Review of the Grievance Policy revealed that a resolution to a patient grievance must be completed within 30 calendar days. Further review revealed a written notification must be sent to the complainant detailing the steps taken to investigate the issue, the resolution, the date the issue was resolved and the telephone number of a staff member who can be contacted.

Based on record review and interview the hospital failed to ensure patients' right to care in a safe setting by:
1) Failing to ensure hospital policy titled "Securing Patients' Personal Property" was enforced for 1 of 2 Grievances reviewed for missing property (Patient #R1).
2) Failing to ensure the hospital remove all beds with no working brake system from the Emergency Department since identifying the problems on 1/21/2010.
3) Failing to ensure patients were assessed for falls as per hospital policy for 1 of 10 sampled patients (#9).

Findings:

1) Failing to ensure hospital policy titled "Securing Patients' Personal Property" was enforced for 1 of 2 Grievances reviewed for missing property (Patient #R1).

Patient #R1:
Review of the hospital grievance log and Patient #R1's grievance file revealed Patient #R1's family filed a grievance on 3/24/2010 regarding money missing from his wallet when returned to him by hospital police. The family claimed Patient #R1 had $50.00 (fifty dollars) in his wallet at the time the wallet was collected by hospital police and upon return there was only $25.00 (twenty five dollars) in his wallet (reported loss of twenty five dollars).

Further review of the grievance file for Patient #R1 revealed no documented evidence of an investigation of this grievance.

Review of the "Valuables Envelope" for Patient #R1 dated 2/18/2010 revealed the following logged items: (1) cell phone, (1) cell phone charger, (1) Black Wallet, (1) LADL (Louisiana Driver s License), (1) SS (social security) card, Misc (miscellaneous) papers, (1) pair of glasses, (1) glass case. " Further review revealed a " Valuables Claim Check " with items listed as "LA (Louisiana) Purchase Card, (4) $5.00 (four five dollar bills), (5) $1.00 (five one dollar bills)." Review revealed this "Valuables Claim Check" to have the signature of one Hospital Police Officer and no other documented staff signature or patient/family signature.

During a telephone interview on 5/11/10 at 3:30 p.m., Sergeant S36 indicated the Hospital Police Officer that signed the Valuables Envelope, without a witness' signature, no longer worked at the hospital due to being out on FEMLA (Family Emergency Medical Leave Act) leave. S36 further indicated it was not necessary for Hospital Police Officers to have a witness for the collection of patient valuables because Hospital Police Officers were trusted employees.

During a face to face interview on 5/12/2010 at 8:55 a.m., Director of Performance S21 indicated the policy for collecting valuables in the hospital pertains to all employees including Hospital Police. S21 further indicated all employees, to include Hospital Police, were to have another staff member or cognitively intact patient present when valuables were collected from a patient. S21 indicated this practice ensured the contents placed in a valuables envelopes had been verified as accurate. S21 further indicated the envelope should contain the signatures of both people involved in verifying the contents placed in valuables envelopes which included the two staff present or the staff and the cognitively intact patient. S21 indicated it was unacceptable for a Hospital Police Officer to take a patients' personal belongings without a witness signature verifying the envelopes' contents.

Review of the hospital policy titled, "Securing Patients' Personal Property, dated 11/30/2009" presented by the hospital as their current policy revealed in part, "Patient Care Services' staff shall inventory and record patients personal property on a Patient Clothes and Valuables form in the presence and under the observation of a Hospital Police Officer. To verify and confirm the inventory of patients' personal property, the Patients' Clothes and Valuables form shall be signed by the Patient Care Services staff member who inventoried and recorded the patient's personal property and the Hospital Police Officer who observed the process."


2) Failing to ensure the hospital remove all beds with no working brake system from the Emergency Department since identifying the problems on 1/21/2010.

Review of a Hospital "Capital Expenditure Request (CER) Form" dated 1/21/10 from the "Department Name: Emergency Department" revealed in part, "Description of Expenditure/ Project: ER (Emergency Room ) Stretchers. Describe Consequences if CER is not approved: requesting stretchers to replace broken and unfixable beds for patient safety issues. . ."

Observations on 5/11/10 at 8:25 a.m. revealed the stretcher located in Room C (room in patient use) to have the brakes (located at the distal end of the stretcher near the floor) in the locked position. Further observations revealed the stretcher was easily moved with full mobility while in the locked position. This finding was confirmed by Registered Nurse S10 on 5/11/2010 at 8:25 a.m. who further indicated the bed was broken and should have been removed from the patient's room.

Observations on 5/11/10 at 8:25 a.m. revealed the stretchers located in Room A and Room B to have the brakes placed in the locked position. Further observations revealed the stretchers could be easily moved with partial mobility while in the locked position (range of movement 6 inches from starting position). This finding was confirmed by Registered Nurse S10.

Face to face interviews were conducted with the following employees:
Registered Nurse S27 on 5/12/2010 at 9:55 a.m.
Registered Nurse S34 on 5/12/2010 at 12:20 p.m.
Both nurses (S27 and S34) indicated there had been an ongoing problem with beds/stretchers in use in the Emergency Department that either did not lock properly or did not lock at all.

During a face to face interview on 5/12/2010 at 11:00 a.m., Director of Performance S21 indicated there should be no beds with broken brake systems located in the Emergency Department due to the safety risk for patients.

3) Failing to ensure patients were assessed for falls as per hospital policy for 1 of 10 sampled patients (#9).

Review of Patient #9's medical record revealed the patient was admitted to the hospital's Emergency Department on 2/05/2010 with the chief complaint of "HA" (headache), cough, weakness, chest discomfort and a past Medical History which included seizures. The patient's diagnosis included Dilantin toxicity. A falls risk assessment was checked as done during the time of triage (9:30 a.m.) and the section of the record indicating "Green armband/dot (hospital tool for identifying fall risk patients) placed" was checked as "no". Further review of the Emergency Department record for Patient #9 revealed documentation at 0040 (12:40 a.m.) indicating "heard a loud thump. found pt. (patient) lying on fl (floor) with feces all over the pt., fl, and curtain. B/P (blood pressure) on monitor 63/23 c (with) HR (heart rate) of 59. pt. possibly post ictal. C (cervical) collar in place. pt. cleaned and placed on a clean gurney". Review of the entire Emergency Department Record for Patient #9 revealed no updated Fall Assessment after the patient was known to have fallen in the Emergency Department. This finding was confirmed by Emergency Department Supervisor (RN) S28 who further indicated Patient #9 should have been identified as a fall risk at the time of her admission to the Emergency Department due to her seizure disorder. S28 indicated it had not been the practice in the Emergency Department to update Falls Risks assessments after patients had fallen in the Emergency Department.

During a face to face interview on 5/12/2010 at 9:55 a.m., Registered Nurse S27 indicated she was the nurse assigned to the care of Patient #9 at the time she was found on the floor post fall (12:40 a.m.). S27 indicated the fall was not witnessed by any staff; however she knew (as documented in the medical record) that the patient's side rails were up. S27 further indicated she knew the bed was locked and in the lowest position because that was her practice. S27 confirmed there was no documented evidence in the medical record or incident report to indicate the bed was locked or that the bed was in the lowest position. S27 further indicated that due to her observations of feces on the floor, the patient, and the curtains in combination with a low blood pressure she believed the patient had a vaso-vagal response when she defecated. S27 indicated it appeared to her as if the fall had occurred after the patient had already gotten out of bed.

During a face to face interview on 5/12/2010 at 10:40 a.m., Registered Nurse S29 indicated any patient with a history of seizures should be identified as a Fall Risk, should have a green band placed on their arm, and should have the fall risk reflected in their medical record.

During a face to face interview on 5/12/2010 at 11:35 a.m., Emergency Department Supervisor (RN) S30 indicated the nursing staff in the Emergency Department should be updating Fall Risks assessments after patients fall in the Emergency Department.

Review of the hospital policy titled, "Fall Prevention Program, last revised 9/29/2008" presented by the hospital as their current policy revealed in part, "The triage sheet of Emergency Department patients who are at risk for falls is also flagged with a green dot. . . The Registered Nurse (RN) / licensed practical nurse (LPN) shall complete a Fall Risk Assessment as a part of the nursing assessment within eight hours of a patient's admission. If deemed appropriate by the RN or LPN, the patient shall be placed on Fall Precautions. . . Each patient shall be re-assessed for fall risk by the nurse, including the potential risks associated with the patients medication . . . with a change in status. . . Risk factors include but are not limited to: . . . History of falls within the last three months. . . Medications: anticonvulsants. . . Patients at risk for falls are identified by the following methods: with fluorescent green armbands. The armbands shall be secured to the patient's wrist and can be removed when the patient's condition warrants, the patient's medical record is flagged with a green dot, the patient's room is flagged with fall precaution signage."

Based on record review and interview the hospital failed to ensure adverse patient events (falls) were analyzed for their cause for 1 of 1 patient falls reviewed (Patient #9). Findings:

Review of Patient #9's medical record revealed the patient was admitted to the hospital's Emergency Department on 2/05/2010 with the chief complaint of "HA" (headache), cough, weakness, chest discomfort and a past Medical History which included seizures. The patient's diagnosis included Dilantin toxicity. A falls risk assessment was checked as done during the time of triage (9:30 a.m.) and the section of the record indicating "Green armband/dot placed" was checked as "no". Further review of the Emergency Department record for Patient #9 revealed documentation at 0040 (12:40 a.m.) indicating "heard a loud thump. found pt. (patient) lying on fl (floor) with feces all over the pat., fl, and curtain. B/P (blood pressure) on monitor 63/23 c (with) HR (heart rate) of 59. pt. possibly post ictal. C (cervical) collar in place. pt. cleaned and placed on a clean gurney". Review of the entire Emergency Department Record for Patient #9 revealed no updated Fall Assessment after the patient was known to have fallen in the Emergency Department. This finding was confirmed by Emergency Department Supervisor (RN) S28 who further indicated Patient #9 should have been identified as a fall risk at the time of her admission to the Emergency Department due to her seizure disorder. S28 further indicated it was not the practice in the Emergency Department to update Falls Risks assessments after patients had fallen in the Emergency Department.

During a face to face interview on 5/12/2010 at 9:55 a.m., Registered Nurse S27 (nurse assigned to Patient #9 at the time the patient fell) confirmed there had been no documentation in the Medical Record or on the Incident Report for Patient #9 regarding whether the patient's bed was in the lowest position, whether the call light was in reach of the patient, if the stretcher brakes were applied, or if the stretcher brakes were working. S27 indicated she documented that the patient's side rails were up.

During a face to face interview on 5/12/2010 at 10:40 a.m., Registered Nurse S29 indicated any patient with a history of seizures should be identified as a Fall Risk and should have a green band placed on their arm and should have the risk reflected in their medical record. S29 indicated Patient #9 had not been placed on Fall Precautions after the fall, as evidenced by failure to have the patient's name in the Fall Risk log located in the Emergency Department and failure to have the patient identified as a fall risk on the Emergency Department record.

During a face to face interview on 5/12/2010 at 11:35 a.m., Emergency Department Supervisor (RN) S30 indicated the nursing staff in the Emergency Department should be updating Fall Risks assessments after patients fall in the Emergency Department.

Review of the hospital policy titled, "Fall Prevention Program, last revised 9/29/2008" presented by the hospital as their current policy revealed in part, "The triage sheet of Emergency Department patients who are at risk for falls is also flagged with a green dot. . . The Registered Nurse (RN) / licensed practical nurse (LPN) shall complete a Fall Risk Assessment as a part of the nursing assessment within eight hours of a patient's admission. If deemed appropriate by the RN or LPN, the patient shall be placed on Fall Precautions. . . Each patient shall be re-assessed for fall risk by the nurse, including the potential risks associated with the patients medication . . . with a change in status. . . Risk factors include but are not limited to: . . . History of falls within the last three months. . . Medications: anticonvulsants. . . Patients at risk for falls are identified by the following methods: with fluorescent green armbands. The armbands shall be secured to the patient's wrist and can be removed when the patient's condition warrants, the patient's medical record is flagged with a green dot, the patient's room is flagged with fall precaution signage."

Observations on 5/11/10 at 8:25 a.m. revealed the stretcher located in Room C (room in patient use) to have the brakes (located at the distal end of the stretcher near the floor) in the locked position. Further observations revealed the stretcher easily moved with full mobility while in the locked position. This finding was confirmed by Registered Nurse S10 on 5/11/2010 at 8:25 a.m. who further indicated the bed was broken and should have been removed from the patient's room.

Observations on 5/11/10 at 8:25 a.m. revealed the stretchers located in Room A and Room B to have the brakes placed in the locked position. Further observations revealed the stretchers could be easily moved with partial mobility while in the locked position (range of movement 6 inches from starting position). This finding was confirmed by Registered Nurse S10.

Face to face interviews were conducted with the following employees:
Registered Nurse S27 on 5/12/2010 at 9:55 a.m.
Registered Nurse S34 on 5/12/2010 at 12:20 p.m.
Both nurses (S27 and S34) indicated there had been an ongoing problem with beds/stretchers in use in the Emergency Department that either did not lock properly or did not lock at all.

During a face to face interview on 5/12/2010 at 11:00 a.m., Director of Performance S21 indicated there should be no beds with broken brake systems located in the Emergency Department due to the safety risk for patients. She further indicated incidents/accidents should be investigated to determine the root cause.

Review of the entire incident report/investigation regarding the fall of Patient #9 on 2/06/2010 at 0040 (12:40 a.m.) revealed no documented evidence of whether the patient had been identified as a fall risk before or after the patient's fall, no documented evidence as to whether the bed was in the locked position, no documented evidence to indicate if the brakes were working properly, no documented evidence to indicate if the call light was in reach of the patient, no documented evidence to indicate the height of the bed, no documented evidence to indicate if the patient was wearing non-skid foot wear (if indicated), and no documented evidence of any other investigative data in attempt to identify and analyze the cause of the patient's fall with the exception of documentation indicating the side rails were up. This finding was confirmed by the Director of Performance S21.

Based on record review and interview the hospital failed to ensure medical records were complete as evidenced by failing to have radiology reports located in the medical records of 4 of 10 sampled patients (#5, #6, #11, #12). Findings:

Review of Patient #5's medical record revealed the patient was treated in the Emergency Department on 04/14/10. Further review revealed physician's ordered for a a right knee x-ray. Review of the entire medical record revealed no documented evidence of the Radiology Report for this x-ray.

Review of Patient #6's medical record revealed the patient was treated in the Emergency Department on 03/04/10. Further review revealed physician's ordered for a CT of Head or Brain with or without contrast. Review of the entire medical record revealed no documented evidence of the Radiology Report for this scan.

Review of Patient #11's medical record revealed the patient was treated in the Emergency Department on 4/23/2010. Further review revealed physician's orders for the following x-rays: Left Ankle. Review of the entire medical record revealed no documented evidence of the Radiology Report for this x-ray.

Review of Patient #12's medical record revealed the patient was treated in the Emergency Department on 4/18/2010. Further review revealed physician's orders for the following x-rays: Right Knee. Review of the entire medical record revealed no documented evidence of the Radiology Report for this x-ray.

During a face to face interview on 5/11/2010 at 11:15 a.m., Regulatory Compliance Officer S2 indicated the hospital used a combination of both electronic documentation and manual documentation. S2 further indicated she did not know why the discharge records for Patients #11 and #12 did not include copies of the radiology reports.

During a face to face interview on 5/11/2010 at 10:00 a.m., Radiology Manager S8 indicated the radiology department sent Batch Radiology Reports to the Medical Records Department and to all hospital units daily. S8 further indicated it was the responsibility for the unit and/or medical records staff to file those reports.

During a face to face interview on 5/12/2010 at 11:35 a.m., Director of Medical Records S32 indicated it had not been the hospital's practice to place radiology reports in the Medical Records for discharged patients. S32 indicated the Department did not file complete medical records that included radiology reports. S32 indicated the only time a medical record would be complete, to include all radiology reports, would be when a patient or another facility requested a patient's medical record. S32 indicated at that time, an electronic search would be conducted and radiology reports would be added to the medical record.