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Based on a review of policies and procedures, the medical record, facility documents, and interview, it was determined the Hospital did not

1) send a written notice to the complainant within seven (7) days, informing complainant of the Grievance resolution, as required by the policy for Patient #2; and

2) define the timeframe needed to resolve the grievance, within the Grievance policy, if unable to complete the investigation within 7 days of the receipt of the complaint.

Findings include:

1) The policy "Patient complaint, Discrimination, and Grievance" requires: "...within seven (7) days of the receipt of the Grievance, provide each patient, patient's representative...notice of it's decision...results of the Grievance...."

Patient #2 was admitted on 11/01/10, for a small bowel obstruction.

A Grievance letter submitted on Patient #2's behalf, was received in Hospital Administration on 01/12/11.

On 02/08/12, the Director of Service Excellence confirmed a written notice was sent to the complainant, dated 01/25/12, informing the complainant that the Grievance investigation was not complete, but that a letter would be sent with the results when the investigation was concluded.

The Director confirmed the written notice was dated thirteen (13) days after the receipt of the Grievance, not within seven (7) days as the policy required.

2) The policy "Patient complaint, Discrimination, and Grievance" requires: "...Where the Grievance cannot be investigated and resolved within seven (7) days, notify the patient that the investigation remains ongoing and that the decision will be provided as soon as the investigation is completed...."

On 02/08/12, the Director of Service Excellence confirmed the current Grievance policy does not have a defined timeframe for completing the Grievance investigation when the Hospital is unable to complete the investigation within seven (7) days of receiving the complaint.

Based on a review of policies and procedures, medical record, and interview, it was determined the registered nurse (RN) failed to restart an intravenous (IV) line per policy, within 24 hours, after the IV was started outside of the facility on Patient #6.

Findings include:

The policy "Intravenous Therapy: Peripheral IV Therapy Practice Guideline for Nursing and Allied Health" requires: "...IV Site Changes...IV sites, bags, and tubing started outside the facility are restarted within 24 hours...."

Patient #6 was admitted on 01/12/11, for weakness, and rule out Hemodialysis catheter infection.

On 02/09/12, the Director of Quality Management (QM) reviewed Patient #6's chart documentation regarding the patient's IV insertion and maintenance care. She confirmed the ambulance staff had documented an IV was started peripherally, in the left forearm, on 01/12/11, at 0805.

She confirmed Patient #6 had an Central Line placed on 01/12/11, at 1700, with the nursing staff documenting this line as #1, and the left peripheral IV as Line #2.

She confirmed on 01/13/12 at 1620 and 1701, and on 01/14/11 at 1200, the nursing staff documented Line #2, had no redness, edema, leakage, or pain.

On 02/09/12, the Director of QM confirmed IV site Line #2, (Peripheral IV in the left forearm), was not changed within 24 hours, as required by policy.

Based on a review of policies and procedures, medical record, and interview, it was determined the Hospital laboratory (Lab) personnel did not complete a Specimen Problem Resolution Form (SPRF), when a contracted laboratory facility reported questionable lab results on Patient #5.

Findings include:

The policy, "Completion of Specimen Problem Resolution Form (SPRF)" requires: "...This procedure applies to all hospital laboratory staff who identify and/or document problems related to specimen collection and/or specimen patient identification...Initiate the...form...after the problem is identified...Forward...to the department supervisor...Complete...the form sections...(Section) Reference lab Issues...#55 Questionable Results Received (when) Laboratory Personnel recognize a discrepancy with previous results...."

Patient #5 was admitted on 06/29/11, for decreased urinary output, and lower extremity edema.

On 02/09/12, the Director of Laboratory (Lab) Services stated testing for Hepatitis B is done at a contracted Lab Facility.

On 06/30/11, Hepatitis B was ordered and blood drawn on Patient #5, with positive results received on 07/01/11.

On 07/02/11, Hepatitis B was re-order and blood drawn on Patient #5, with negative results received on 07/03/11.

The Director confirmed the Lab technician who receives the questionable lab results must complete a "Specimen Problem Resolution Form (SPRF)," at the time the Lab technician is notified.

She confirmed there is no evidence of a completed SPRF, regarding the questionable Lab results on Patient #5.