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Based on interviews and record reviews, it was determined that the hospital staff failed to investigate 1 of 3 complaints (received by the hospital) selected for review (Patient #4 was the patient named in the complaint).

The findings include:

The hospital staff failed to investigate a complaint filed by Patient #4's spouse.

Review of hospital records indicated a 'non-physician complaint' was 'submitted' on 9/3/13. The survey team was given: (a) a copy of the complaint letter received by the hospital (the complainant was the spouse of the patient), (b) a copy of the letter from the hospital staff responding to the complainant, and (c) a 'review' document that listed communication between hospital staff related to the complaint which included the statement, "Closed with Resolution."

Review of the hospital policy entitled, 'Patient - Guest Complaint and - or Grievance Management,' revealed the following information under the 'procedure' section of this policy: "The director or their designee will initiate the review and investigation of the grievance. The director or their designee will be responsible for routing additional information to the other Directors who will be involved in the resolution of the grievance ... The Director or their designee will log findings, actions, and/or interventions to grievance resolution to the on-line Patient/Guest Feedback System."

The complaint letter included the following concerns: (a) not being able to have the patient admitted to his/her primary care physician instead of a hospitalist, (b) not have constipation addressed/treated, (c) incorrect discharge information provided to the home health agency, and (d) difficulty in obtaining information after discharge related to his/her spouse's hospital treatment. No details of an investigation of the alleged concerns were provided to the survey team; on 6/4/14 at 12:15 PM, Staff Member #3 (a quality coordinator) was asked for the investigation details. On 6/4/14 at 1:25 PM, Staff Member #3 reported that no evidence of investigation of the complaint was found.

Based on interviews and record reviews, it was determined the facility staff failed to ensure complete and accurate clinical records for 2 of 10 sampled patients (Patient #4 and Patient #1).

The findings include:

1. Patient #4's clinical record revealed incomplete and/or inaccurate clinical documentation.

Review of Patient #4's 'Discharge Summary Report' (dictated on 2/6/14 at 1:43 PM) revealed the following information under the 'HOSPITAL COURSE:" section: "(His/her) sputum grew E coli. (He/she) was switched to Rocephin at that time."

Review of Patient #4's clinical record failed to reveal orders for a sputum culture and failed to reveal orders for the antibiotic Rocephin. During an interview on 6/4/12 at 4:00 PM, Staff Member #13 (a registered nurse assisting with record reviews) confirmed no order for a sputum culture and no order for the antibiotic Rocephin was found.


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2. The surveyor review of the medical record for Patient #1 on 6/4/2014 and 6/5/2014 which revealed the following:
? An admit date of 5/22/2014 and a discharge date of 6/5/2014.
? An order received to discharge patient home on 5/25/2014 at 09:47, same order discontinued at 12:25 on 5/25/2014.
? A document titled "Discharge Summary Report" with discharge date 5/25/2014 which detailed the clients discharge home on that date.
? The client remained a patient for more than 10 (ten) days following 5/25/2014 and was discharged home on 6/5/2014. Review of medical record failed to reveal any correction or addendum to "Discharge Summary Report" dated 5/25/2014, after the discharge scheduled for 5/25/2014 was discontinued by the physician.
? A document titled "Discharge Summary Report" with discharge date 6/5/2014 which detailed the clients discharge home on that date.
During the end of day review with the management team on 6/5/14, when discussing the "Discharge Summary Report" dated 5/25/2014, Staff #11 (Risk Management) and Staff #12 (Medical Staff Services, Virginia) agreed that a correction to the record should have been made when the client wasn't discharged as stated in the aforementioned document.