HospitalInspections.org

Based on interview, review of facility policy/procedure and review of the complaint/grievance reports, it was determined the facility failed to document and thoroughly investigate a verbal complaint/grievance and failed to follow facility policy relative to communicating investigative finding to a complainant.

This effected medical record (MR) # 7, 1 of 10 records reviewed and had the potential to negatively affect all patients requiring services of the facility.

Findings Include:

Title Description: Patient/Customer Concern/Grievance
Department: Organization-wide
Personnel: All hospital Personnel
Effective Date: 5/83
Last Reviewed date: 4/09

"Purpose:

A. To describe the process for the prompt resolution of a patient grievance regarding an alleged violation of patient rights as mandated by the Centers for Medicare and Medicaid Services (CMS)...

C. To assure that there is a mechanism for referral of patient concerns regarding quality of care...

Procedure:

A. Concerns reported/Encountered

1. When a staff member receives a patient/customer concern, they will take immediate action as appropriate in an attempt to correct the concern.

2. The Department/Nurse Manager will review and investigate all findings and assure that remedial action was taken, documentation is complete, and forward this as needed back to the Administrative Staff.

3. The Administrative Staff will listen to and interview patient and/or family members, visitors, etc., or carefully study an interaction to identify the problem.

4. He/She will discuss the situation with those who may potentially be involved...


C. Documentation and Evaluation of Action Taken

All patients, visitors and/or family complaints, concerns, request for assistance, etc., that are brought to the attention of the Administrative Staff will be documented. This will be updated to contain a database with factors critical to a complaint. These include date and time of complaint, information referral source, nature of complaint, staff member assigned to the case, patient identification, actions taken as follow-up, correspondence generated, outcome assessment, etc.

D. Follow-Up

Follow-up with patient or family members as appropriate will be done to assure that, when possible, there is a resolution of complaints concerning quality of care and to determine the level of satisfaction...


The Department/ Nurse Manager will in the course of an investigation:

1. Evaluate the occurrence based on the patient or family contact and take appropriate action.

2. Contact appropriate staff members or department in order to notify them of concerns and work towards a solution.

3. Advise the patient or family members of what action is being taken as appropriate and express appreciation for bringing the matter to the hospital's attention".

Title Description: Patient Rights

"Policy:

Springhill Memorial Hospital respects the rights of the patient and recognizes that each patient is an individual with unique healthcare needs. Because of the importance of respecting each patient's personal dignity, Springhill Memorial Hospital provides considerate and respectful care focused upon the patient's individual needs..."


1. MR # 7 was admitted to the facility on 8/16/14 with a diagnosis of Congestive Heart Failure (CHF) Exacerbation and expired on 9/9/14.


Review of the complaint and grievance log from 7/8/14 through 9/26/14 failed to include documentation of a grievance/complaint related to MR # 7.

An interview conducted with Employee Identifier (EI) # 1, Director Quality Improvement/Risk Management on 3/18/15 at 9:10 AM verified the above findings. During the interview, EI # 1 stated EI # 4, Director of Patient Relations, had received a telephone call from the patient's family member regarding the complaint and asking why no one had contacted her. EI # 4 told the family member he/she would return the call the following day. There was no documentation of the telephone call from the family member. There was no documentation a telephone call was conducted by EI # 4 returning the family members telephone call the following day.


An interview conducted 3/16/15 at 3:10 PM with Employee Identifier (EI) # 2, Patient Relations Representative, verified that a complaint had been called into him/her on 9/5/14 by the family member of MR #7 and stated he/she responded to the complaint. EI # 2 stated all complaints are not registered in the log. "The ones that I can resolve does not go in the grievance/complaint log". EI # 2 stated he/she thought the complaint had been resolved that same day, 9/5/14, and did not contact the family member after that encounter.


Further review of the complaint/grievance information revealed a letter addressed to the Nursing Administrator, dated 9/25/14 from MR # 7's family member addressing the complaint which was registered on 9/5/14.

An interview with EI # 3, Nurse Manager, was conducted 3/17/15 at at 2:00 PM . During the interview, EI # 3 was asked how he/she investigated a complaint? EI # 3 stated the complaint would first be referred to EI # 2. After EI # 2, Patient Relations Reoresentative, had tried to resolve the complaint with no results, then the complaint would be returned to EI # 3 for further investigation. EI # 3 stated he/she did investigate the complaint.

Based on review of the medical records, policies and procedures and interviews, it was determined the facility failed to ensure the nursing staff responded to the family's concerns and provided patient care timely.


This affected MR #7, 1 of 10 medical records (MR) reviewed, and had the potential to negatively affect all patients served by the facility.

Findings include:

"Title/Description: Assessment and Reassessment...

Effective: 8/1996

Revised: ...12/14...

Purpose:
To determine what kind of care is required to meet a patient,s initial as
well as his/her needs as they change in response to care

Policy: ...

8. Patients will be reassessed every four hours and PRN (as needed) as condition warrants..."
........

1. MR # 7 was admitted to the Intensive Care Unit (ICU) of the facility on 8/16/14 with a diagnosis of Congestive Heart Failure (CHF) Exacerbation.

Review of the MR revealed MR # 7 was transferred out of the ICU on 9/1/14 into a patient room.

Review of the Nursing General Assessment dated 9/5/14 at 7:10 AM revealed the skilled nurse documented a complete head to toe assessment. Documentation included the following:

"Neuro: alert and oriented x 3...

Cardiac: skin warm and dry to touch, capillary refill < 3 seconds, no pain...

Respiratory: Reparations are regular, breath sounds all lobes are adequate, oxygen in use by a re-breather mask at 15 liters per minute...

Pain: adult scale pain is 0, patient states..."

Review of the next entry in the nurse note by a skilled nurse was documented on 9/5/14 at 12:40 PM. Documentation included the patient was transferred to the ICU.

Review of the "Detailed Staff Activity Report" (A system to register the time of entrance and the length of time staff is in a patient's room) dated 9/5/14 at 7:00 AM to 9/5/14 at 11:59 AM revealed the Registered Nurse (RN) entered the patient's room at 7:05 AM, with documented time in room 0:54 seconds, and at 8:37 AM, with documented time in room 2 minutes and 40 seconds.

Review of the "Detailed Call Report by Location" (a system registering what time calls from the patient rooms are received) revealed a call from MR # 7's room was registered on 9/5/14 at 8:02 AM, 10:36 AM and 10:56 AM. There was no correspondence documented the nurse answered the patient's call for assistance. There was no documentation the needs of the patient was met.

An interview conducted with Employee Identifier # 1, Director Quality Improvement/Risk Management on 3/18/15 at 9:10 AM verified the above findings. This was also verified by EI # 3, Nurse Manager in an interview conducted 3/17/15 at 2:00 PM.