HospitalInspections.org

Based on document review and interview the facility failed to ensure the implementation of the policies related to patient and/or family complaints and their prompt resolution for 1 of 1 family who lodged a complaint with nursing staff, (for Patient #10).

Findings Included:
1. Review of the policy Patient Rights and Responsibilities, policy number PT03.19, last approved 4/14/14, indicated on page 3 under 3.11: "Lutheran hospital supports and facilitates the resolution of complaints from patients and their families...".

2. Review of the policy Patient Complaint/Grievance Management, policy number PT03.43, last approved 4/29/15, indicated on page two under "Policy": 1. Patients have the right to express concerns and expect resolution in a timely manner. And, under "Procedure", on page 3.: "1. In the event a patient or the patient's family or representative have a comment, complaint, or grievance he/she is encouraged to do one or more of the following: Inform or ask any staff member; Speak to the Manager of the area involved; Request to speak with someone in Administration; Other complaints may be received anonymously or from patient/family satisfaction surveys or comment cards."

3. At 11:20 AM on 12/29/16, interview with staff member #54, the director of MSIC (med/surg intensive care) and ortho/neuro med/surg, confirmed that:
A. This staff member met with patient #10's family regarding "concerns" they had with "bruises and marks" on the patient's arms that were not present on arrival to the facility.
B. Patient #10 had encephalopathy and was stating "they're hurting me - get me out of here" to the family.
C. Physician D1 had a meeting with the family regarding the continuation of dialysis, the patient's refusal of dialysis and lab work, the family requesting no medication be given for agitation, and other patient care issues.

4. Review of the log of complaints/grievances in the Event Reports system indicated none was listed/present for patient #10.

5. At 12:00 PM on 12/29/16, interview with staff member #54 confirmed that:
A. This staff member failed to make any notes in the medical record for patient #10 regarding the statements made by the patient's family regarding the patient's bruising, or other questions/complaints.
B. This staff member failed to log the complaint issues made by the family of patient #10 in the reporting system of the facility.
C. It cannot be determined, based on the lack of documentation, that a resolution occurred to the patient/family complaint(s) lodged.