HospitalInspections.org

Based on document review, policy review, and staff interview the facility failed to ensure the complaint voiced by a patient's representative was identified and investigated as a complaint/grievance as per their own policy.

Findings were:

Review of patient #1 medical record on 12/27/16 revealed the patient sustained an injury to 2 fingers on the right hand when his fingers were smashed in the door hinge of the bathroom door on 8/20/16.

Review of email notes of the chief nursing officer to patient #1 on 9/7/16 states the following "I spoke to XXXX via telephone and he gave me verbal consent to share any information/findings regarding his case with his son." Email from the chief nursing officer on 9/14/16 titled "Patient Complaint" stated she spoke with the son about the event with his father and she considered the matter resolved.

Facility policy titled "Patient/Representative/Grievance/Complaint" states in part, "Patient Grievance: A grievance occurs if the complaint is expressed by the patient or his/her representative. If a patient is satisfied with care but a family member is not, no grievance exists. A written, faxed, or emailed complaint is always a grievance whether the patient was an inpatient or outpatient, as is a complaint telephoned in post discharge. Senior administration will provide the patient or the patient's representative with written notice of its decision in a language and manner the hospital can reasonably expect the patient/patient's representative to understand."

In an interview with staff #2 she stated the incident was not considered a grievance as the patient was satisfied with their care. She further stated after her review of the above documents that the patient's son was given permission to be his representative and as the patient's representative could file a grievance/complaint on the patient's behalf as per facility policy. She furhter stated there was no follow up with the patient after conversation with the patient's representative to ensure the patient was satisfied with the resolution on their behalf.

Based on medical record review, policy review, and staff interview the facility failed to ensure physician's completed the history and physical on patients within 24 hours of admission. 1 of 5 charts reviewed was deficient.

Findings were:

Review of medical records on 12/27/16 revealed patient #1 was admitted on 8/19/16. The history and physical for the admission was dictated on 10/11/16.

Facility policy titled "History and Physical" states in part "A patient being admitted to the hospital must have a history and physical completed no more than seven (7) days prior to admission or within twenty-four (24) hours after admission describing the patient's current condition."

In an interview with staff #3 she confirmed the patient is to have a history and physical completed within 24 hours of admission and this medical record did not comply with their policy.

Based on medical record review, policy review, and staff interview the facility failed to ensure complete and accurate documentation in the patient medical record as per facility policy.

Findings were:

Review of medical record for patient #1 on 12/27/16 revealed the patient sustained an injury to his right fingers on the evening of 8/20/16. X-rays revealed a fracture and documentation by the nursing staff revealed the patient had stitches and a bandage on his right hand fingers. Review of the physician progress note for 8/21/16 revealed no mention of the hand injury on the physician progress note. Documented progress note was "Musculoskeletal: Normal range of motion, Normal strength, No tenderness, No swelling." This exact notation was on the progress note on 8/20/16.

Facility policy titled "Content of Record of Admission" states in part "Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of test and treatments."

Discharge Instructions given to the patient on the date of discharge state: "Call to schedule appointment with family doctor for right hand sutures and wound." No documented wound care instructions were provided to the patient from the hospital staff at the time of discharge.

In an interview with staff #1 and #4 on 12/27/16 neither could provide documentation of the physician noting the patient injury and education of follow up in the care of the injury provided to the patient at the time of discharge.