HospitalInspections.org

Based on review of facility policies and documents and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that resolution of formal complaints were timely for four of five grievances reviewed (MR2, MR3, MR4, and MR5).

Findings include:

Review of facility policy "Patient Complaint and Grievance Management" dated September 2014, revealed, " ...D. Response to Grievances: 1. Written Response: On average, a written response addressing resolution of the grievance will be sent to the grieving party within seven (7) days of receipt of the grievance. ... "

1) Review of facility documents revealed a grievance of MR2 that was received by the facility on April 14, 2015. Further review revealed that the facility sent a written response on April 27, 2015.

2) Review of facility documents revealed a grievance of MR3 that was received by the facility on May 29, 2015. Further review revealed no documentation that a written response was sent by the facility.

3) Review of facility documents revealed a grievance of MR4 that was received by the facility on February 22, 2015. Further review revealed that the facility sent a written response on March 3, 2015.

4) Review of facility documents revealed a grievance of MR5 that was received by the facility on January 20, 2015. Further review revealed no documentation that a written response was sent by the facility.

Interview with EMP1 on June 16, 2015, at approximately 2:00 PM confirmed the above findings and revealed, "These letters did not go out on time."

Based on a review of the facility's Performace Improvement Plan and staff interview (EMP), it was determined that the facility failed to specify the frequency of the QAPI data collected.

Findings include:

1) Review of the facility Performance Improvement Plan, August 2014, June 15, 2015, revealed there was no documentation of frequency of data collection specified.

2) Interview with EMP6 on June 17, 2015, confirmed the above and stated, "there is no documentation of the frequency of data collection."

Based on observations and review of facility policy, and staff interview (EMP), it was determined that the facility failed to adhere to accepted standards of practice for infection control by not fully covering their head hair in the operating room surgical suite for two of two surgeries observed (MR32 and MR33).

Findings include:

Review of facility policy "Surgical Services" dated June 2014, revealed "...All possible head and facial hair, including sideburns, must be covered completely by a one-time scrub cap or surgical hood while in the restricted area of the surgical area. ..."

1) During MR32's surgical case on June 16, 2015, at approximately 10:20AM, EMP13 and EMP14 were observed wearing head coverings in the operating suite without fully covering head hair.

2) During MR33's surgical case on June 17, 2015, at approximately 1:17 PM, EMP15 and EMP16 were observed wearing head covering without fully covering their head hair.

3) On June 17, 2015, at approximately 1:30 PM, EMP17 confirmed the above observations and revealed "...hair should be covered... ."