HospitalInspections.org

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Based on record review, interview and policy review, the facility failed to provide a written response of its investigations and outcomes related to grievances for 12 complainants out of 14 complaints reviewed. This practice denied 12 patients and/or their representatives the right to be informed in writing of the steps taken, and resolution of their grievances. Findings:

Record review on 1/31/19 of the "Corporate Integrity and Compliance Program Grievance Complaint Log Summary Report 2018", for the time period between 1/22/18 and 1/21/19, revealed no documented evidence that a written response had been sent to 12 complainants during this timeframe.

During an interview on 2/1/19 at 1:25 pm, the facility's Director of Quality and Risk Management confirmed the facility had not responded in writing to the 12 complainants on the "Corporate Integrity and Compliance Program Grievance Complaint Log Summary Report 2018".

Review of the facility's policy titled "ADM-100 PATENT RIGHTS AND RESPONSIBILITIES", revised 9/2018, revealed " ...You have the right to be informed in writing about the hospital's policies and procedures for initiation, review and resolution of patient's complaints."

Review of the facility's policy titled "QUA-107 PATIENT GRIEVANCE PROCESS", revised 2/2016, revealed " ...D. Director of Quality Assurance and Risk Management for St. Elias will review all complaints, investigate, and generate the acknowledgement letter to be sent to the patient or person making the complaint. Further review of this policy revealed " ... All resolutions to complaints will include written notice of the facility decision, which contain the name and information pf the St. Elias contact person, the steps taken on behalf of the patient to investigate the complaint and the date of completion."

Review of the facility's policy titled "QUA-105 CONCERNS, COMPLAINTS AND GRIEVANCES", revised 2/2016, revealed " ...Administration in conjunction with Quality Assurance and Risk Management Director, Coordinators or designee, in its resolution of the grievance, provides the patient or patient's representative with written notice within 30 business days of its decision that contains: ... Steps taken in the investigation; Results of the grievance process and Completion date."

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Based on interview and record review the facility failed to establish policies and procedures for notification and documentation of potentially contaminated and/or tainted blood to 17 patients of 17 patients who had recieved blood products at the facility since 9/1/18. This failed practice placed 17 patients at risk for lack of notification of contaminated and/or infectious blood products.. Findings:

During an interview on 1/30/19 at 10:45am, the Lab Manager (LM) when asked about notifying patients who have received an infectious blood product, the LM replied he/she did not know of a facility process for notifying patients. The LM further stated blood products come to the facility from Providence Alaska Medical Center Blood Bank (PAMC-BB) and they (PAMC-BB) would notify the patient or the doctor.

During an interview on 2/1/19 at 8:45 am, with PAMC-BB Technical Specialist with blood transfusion service stated, the protocol for PAMC-BB is the Medical Director of the PAMC-BB notifies the ordering provider of the administering facility they have on file. The facility who administers the blood or blood product is then responsible for notifying the patient and/or family of the patient.

Record review on 2/1/19 of the facility's policies revealed no policy for notifying and documenting of patients or their legal representative of whom had received contaminated or infectious blood products.

During an interview on 2/1/19 at 1:20 pm, the Director of Quality and Risk Management stated the facility does not have a process/policy for notifying patients or their legal representative when they have received tainted blood after transfusion.

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