HospitalInspections.org

Based on record review and interview, facility failed to ensure an effective process for resolving grievances. The facility failed to fully investigate patient's grievance in 1 of 3 patients (ID # 1).

Findings include:

Record of facility policy and procedure titled "Patient Complaints and Grievances" dated 6/3/2022 showed the following information:

DEFINITIONS: A "patient grievance" is a formal or informal written or verbal complaint that is made to the health care system by a patient, or patient's representative, regarding the patient's care) when the complaint is not resolved at the time of the complaint by staff present) ...

POLICY STATEMENT:
4. Grievancees are incorporated into performance improvement and patient safety activities.

PROCEDURE:
ACTION:

7.Department leadership will investigate the grievance including, as appropriate, clinical reviews and staff interviews.
8. Document findings in hospital approved electronic tracking tool or send results to patient relations team ...



Review of patient relations worksheet for patient (ID# 1)
Synopsis-included but not limited to the patient stating that they are allergic to specific suture that was used during her surgery.
Grievance was closed with no documented investigation regarding suture usage in the opeating room.

Interview with patient relations staff (ID# 72) on 2/29/2024 at 1:45 PM, she confirmed the above findings.

Interview with facility CMO (ID# 54) on 2/29/2024 at 1:08 PM confirmed the above findings, stating that there some gaps in this grievance investigation/process.

Based on record review, and interview, the facility failed to ensure 2 of 3 patients received post anesthesia assessments prior to discharge from the post anesthesia care unit (PACU) due to inconsistent process (ID#s 10 and 12).

Findings include:

Record review of facility Rules and Regulations for the Medical Staff showed the following information:
L. The Anesthesiologist

The anesthesiologist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic evaluation follow-up of the patient's condition.

Medical record review for patients (ID#s 10 and 12) on 2/29/24 at 9:25 AM for date of service 2/28/2024 showed no completed post anesthesia assessment.

Interview with perioperative services manger (ID# 62) on 2/29/24 at 9:25 AM, she confirmed the above findings and stated that patients are to receive a post anesthesia assessment prior to being discharged from the PACU.

Interview with anesthesiologist (ID #66) on 2/29/24 at 9:30 AM, he stated that the post anesthesia assessment is to be completed on the paper anesthesia form.

Interview with chief of anesthesia (ID# 67) on 2.29/24 at 9:45 AM, she stated that the post anesthesia assessment is usually completed on the paper form but providers could also document in the computer.

No evidence of computer documentation of post anesthesia assessment was provided while surveyor was on site.

Interview with staff RN (ID# 63) on 2/29/24 at 9:50 AM, she stated that when patients meet criteria, they are moved to phase II PACU and are discharged from there. The vital signs are documented on the anesthesia assessment sheet but we do not wait for them to get signed before moving the patient. The anesthesia paper is kept to be signed by the anesthesia person to sign as they periodically are coming through checking on patients.

Interview with staff RN (ID# 64) on 2/29/23 at 9:53 PM, she stated that patients are moved to Phase II when criteria is met. Anesthesia will see them at some point before they are discharged.

Interview with staff RN (ID# 65) on 2/29/24 at 9:55 stated that she is not sure when anesthesia will get back around to see patients in PACU as they may be busy in pre-op. She stated that when patient criteria is met, they go to the next phase. If there is an issue with their condition we can call anesthesia.