HospitalInspections.org

Based on staff interview, policy review and record review it was determined the Patient Advocate and the Patient Safety Manager both failed to follow the hospital policy for filing a complaint on behalf of a patient who wished to file a complaint in one (1) of one (1) charts reviewed. This failure has the potential to adversely impact all patients that wish to file a complaint in this facility.

Findings include:

1. An interview was conducted on 5/9/16 at 3:20 p.m. with the Patient Advocate and when asked if she remembered a complaint coming into the hospital concerning patient #1 she stated: "I took the phone call and when they mentioned neglect I felt the Director of Safety would be the person to handle the call since they mentioned neglect". When asked if she filed an occurrence report she stated: "No, that isn't part of my job, I don't fill out those reports." When asked if she felt the Director of Eagle Point was filing a complaint she stated "Yes."

2. An interview was conducted on 05/10/16 at 3:10 p.m. with the Patient Safety Officer. When asked if he was aware of a complaint from Eagle Point Nursing Home he stated: "I took the phone call when the patient advocate transferred the call to my office. The Director of Eagle told me he needed to report neglect "he thinks ". He said they [The Wound Center] didn't take a photo. He then stated: "The wound is getting bigger because of debridement and we can't get the blame for it." The interview further revealed the Director of Eagle Point told the patient safety officer "We are a two star facility and if Center of Medicare and Medicaid (CMS) comes we need to have documentation that we have reported this, so I'm probably also turning you into CMS". He stated further: "I did not see this as neglect, maybe as documentation issues." When asked if he filed an occurrence report he stated: "No, I didn't see this as neglect so I did not file a report."
3. Review of the policy titled "Occurrence Reporting" with an effective date of 9/2/15 revealed in part "All hospital staff - It is the responsibility of all hospital staff to report any occurrence constituting or discovering the occurrence to management personnel...and complete an online Occurrence Report".

4. Review of the policy titled "Complaint Management" with an effective date of 2/2/15 revealed in part "Each patient/family complaint will be documented utilizing hospital-provided computer generated complaint management form located in the meditech system".

5. Review of the job description for the Patient Advocate revealed in part "Demonstrates knowledge of Risk Management/Occurrence Reporting /Non-punitive work environment".

6. Review of the job description for the Director of Risk Management (Patient Safety Officer) revealed in part "Demonstrates knowledge of Risk Management/Occurrence Reporting/Non-punitive work environment".

7. During the interview with the Patient Safety Director on 5/10/16 at 3:10 p.m. he concurred with the above findings.