HospitalInspections.org

Based on documentation review, it was determined:
1.) the Hospital's Grievance Process did not specify time frames for the review of grievances and/or for the provision of a grievance response.
2.) the Hospital did not respond to 2 Grievances/Complaints received during the time period of 6/15-9/15/10 in a timely manner.

Findings included:

1.) The Hospital's policy/procedure titled "Patient Complaint Management" (#12-5) indicated the Case/Quality/Risk Management Department is responsible for operating and maintaining the grievance mechanism designated to process and resolve patient complaints. The Policy/Procedure also indicated the Case/Quality/Risk Management Department would: log the Complaint; investigate the Complaint and; communicate the outcome of the Investigation to the patient. The Policy/Procedure did not specify time frames for the review/investigation of the grievance/complaint and/or for the communication of the outcome of the complaint/grievance investigation.

2.) Documentation indicated the Hospital received a Letter of Complaint regarding Patient #1's care from Patient #1 on 8/10/10 and a Complaint Investigation was conducted, but as of 9/23/10; the results of the Investigation had not been communicated to Patient #1.

Documentation indicated the Hospital received a Letter of Complaint from Patient #6's son on 9/8/10 and a Complaint Investigation was in process, but as of 9/23/10; the Investigation was not complete.

Based on documentation review, it was determined the Hospital failed to respond to a Grievance/Complaint with a Written Notice of Decision containing the name of a Hospital contact person, the steps taken to investigate the Grievance/Complaint, the results of the Grievance/Complaint Process, and the date of completion.

Findings included:

Documentation indicated Patient #7 communicated concerns/grievances regarding his/her Hospital care on a Patient Satisfaction Survey received by the Hospital on 9/8/10 and the concerns were related to physician communication and discharge planning. Documentation also indicated the Director of Surgical Services spoke with Patient #7 on 9/13/10. As of 9/23/10, Patient #7 had not been sent a Written Notice of Decision (containing the name of a Hospital contact person, the steps taken to investigate the concerns/grievances, the results of the Grievance/Complaint Process, and the date of completion.

Based on interview and documentation review, it was determined the Hospital had not (yet) developed and implemented its Corrective Action Plan related to its investigation of a Complaint regarding Patient #1's Hospital care.

Findings included:

Documentation indicated the Hospital received a Letter of Complaint regarding Patient #1's July 2010 Hospital care from Patient #1 on 8/10/10. In the Letter, Patient #1 alleged that he/she; a left hand-dominant patient admitted to the Hospital following a motor vehicle accident on a Friday before a 3-day holiday weekend with multiple fractured ribs and a left wrist fracture with carpal dislocation, was not transferred to a tertiary care hospital for definitive treatment of the wrist fracture in a timely manner, and that: his/her wrist fracture should not have been allowed to remain in a dislocated position while at the Hospital; a more timely transfer would have resulted in an accelerated timeline for necessary wrist surgery and a more satisfactory result for him/her and his/her health insurance providers, and that; his/her recovery was prolonged because of the delay in transfer.

Documentation indicated an Investigation related to Patient #1's Complaint determined that a locum tenens (a physician who temporarily substitutes for another) orthopedic surgeon who cared for Patient #1 over the holiday weekend (Orthopedic Surgeon #1) did not know the orthopedic surgeons on staff at the Hospital did not treat complex wrist fractures and therefore did not initiate a Patient transfer (prior to the staff orthopedic surgeon's return).

A review of the Corrective Action Plan related to the Hospital's investigation of Patient #1's Complaint revealed it called for the development of Orthopedic Service treatment/transfer criteria for locum tenens orthopedic physicians.

The Hospital's Chief Operating Officer was interviewed in person throughout the On-site Investigation. He/she said the Hospital's Orthopedic Surgeons were scheduled to meet to develop the Orthopedic Service Treatment/Transfer Criteria on 9/27/10. He/she also said compliance with the Treatment/Transfer Criteria would be monitored.