HospitalInspections.org

Based on document review and interview the facility failed to act on a patient complaint/grievance in one of one grievances identified.

On 2/11/2011 at 10:00 AM a review of facility policy titled: Patient Complaint/Grievance Resolution Process revealed the following: Section I GENERAL STATEMENT: The facility provides a process to assure the rights of the patient and their family to register complaints or grievances and that identified issues or concerns are communicated in a timely manner....

Section II POLICY A. Definitions: 1. Complaint. * Expressed displeasure with a process or person. * An expression of dissatisfaction with some aspect of care or service, * An issue resolved by staff present or within the same day, or by the Patient Service Representative. 2. Grievance * A formal or informal, written or verbal complaint, made to the hospital by a patient, or patient's representative.... A written complaint is ALWAYS considered a grievance.

Section II POLICY A .3.* Information obtained with a patient satisfaction survey does not usually meet the definition of a grievance UNLESS an identified patient attaches a separate letter to the survey. (The patient's daughter attached a three (3) page letter of complaint to the satisfaction survey)

Section II POLICY C. Process, 2. b). For all grievances, investigation will begin and an initial contact letter will be sent to the complainant ....within 7 days. 2. c). The Administrator or designee will log the grievance. 2. e). A response letter.... provided to the person issuing the grievance out lining steps that were taken to investigate the grievance, results of the investigation and the date of completion....

On 2/1/2011 at 10:15 AM a review of the patient's Emergency Department record revealed the nurses note narrative recorded the following: "2200 hrs Pt's daughter angry wants patient bathed. Wants patient transferred..." There is no documentation addressing the requested bath.

On 2/1/2011 at 10:30 AM an interview with staff # 2 revealed the following: 1) no documentation a 7 day initial contact letter had been sent. Staff # 2 indicated the satisfaction survey had been received approximately 2 weeks earlier. 2) The complaint had not been logged. 3)There was no documentation that any aspect of the grievance had been addressed. There was no documentation that a response letter had been provided outlining the steps that were taken to investigate the grievance, results of the grievance process and date of completion.

Staff #2 had forwarded the letter to the ED Director and the Director of Admissions. Staff #2 indicated the investigating was still on going.

Based on record review and interview, the facility failed to have current Emergency Department (ED) policies readily available to staff.


Findings include:

During a tour of the ED on 2/1/11 at 1000, no ED policy and procedure manual could be found. The trauma specific policy and procedure manual was available.

In an interview in the ED break room on 2/1/11 at 1010, the Chief Clinical Officer (CCO) reported that when the last ED Director left, the ED policy and procedure manual could not be found in either printed or computer file form. The CCO reported that the previous ED director left in June 2010 and that the current ED director (staff#3), hired January 2011, was currently creating a new policy and procedure manual.

In an interview in the ED break room on 2/1/11 at 1010, staff #3 confirmed the CCO's report.