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Based on the documentation in the "Guestline Complaint/Grievance Resolution" policy, medical record review, and interviews, the Governing Body failed to ensure staff members followed the facility's current policy relative to patient/family complaints, and failed to assure the telephone numbers in their current policy were accurate.
This deficient practice effected PI# 1, one of ten sampled patients.
Findings Include:

1. The hospital policy entitled "Guestline Complaint/Grievance Resolution," dated and approved by the hospital's Quality Improvement Committee on 10/28/2008 includes:
"I. Purpose:
...strives to provide quality medical care in an atmosphere of care and concern for patients/family provides several mechanisms for patient/family members/surrogate decision makers/visitors. We encourage patients/ family members/surrogate decision makers/visitors to voice any concerns regarding their experience for quick and effective resolution.
II. POLICY:
...provides several mechanisms for the patient/ family members/surrogate decision makers/visitors to voice concerns or unmet needs. Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, unreasonable interruption of care, treatment and services. All employees and/or department management are available to assist those who express concerns. In addition, a guest relations representative is available to work on behave of the patient/family representative is available to work on behalf of the patient/family member/surrogate decision maker/visitor in resolving concerns or meeting needs.

Any employee receiving a complaint will immediately attempt to correct the problem. The concern will be referred to the appropriate manager. Guest Relations representative or Guest Line (by dialing...) if resolution is outside of his/her scope of responsibility, or cannot be resolved on the spot.
Guest Relations is available to any patient, family member, vendor, guest, community member, and visitor from 09:00 a.m.-9:00 p.m., Monday through Friday. During other times, complaints/grievances are to be directed to the Nursing Supervisor or through the Guest Line.

Patients may file grievances with the State of Alabama Department of Public Health by calling...or in writing...If they have a complaint regarding quality of care, disagreement with a coverage decision, or they wish to appeal a premature discharge. A complaint can be submitted by calling...
III. PROCEDURE:
1. Information:
Upon admission, all patients receive written information explaining their right to report any concern or dissatisfaction/complaint/grievance in the Guest Information Brochure and the admission ' s memorandum. " Your Rights and Responsibilities and Our Organization Ethics. " Medicare patients receive an additional instruction material entitled, " An Important Message from Medicare about Your rights. " Information is also posted throughout waiting areas and in patient rooms.
2. Complaint/Concern or Dissatisfaction is defined as: a verbal complaint that can be resolved at the time of complaint by staff present.
a. A complaint/concern/dissatisfaction can be filed with any hospital employee, volunteer, physician.
B. A complaint/concern/satisfaction can be resolved to the customer ' s satisfaction by implementing a change or response in a timely manner.
C. Employees receive training to encourage and teach our service recovery philosophy and methodology.
3. Grievance is defined as: a written or verbal complaint that cannot be resolved at time of complaint by staff present.
A. Guest Relations/Quality Management/Risk Management will be responsible for responding to formal grievances.
B. Guest Relations/Quality Management/Risk Management will act as liaison between the medical/hospital staff, administration, and the customers.
C. If the complainant wishes to verbally state their grievance, needed information will be documented.
D. Grievances made by telephone call or letter from discharged patients will be forwarded to Guest Relations.
E. If it is determined that anonymity is important, or if the complainant requests it, the anonymity of the patient will be provided for by excluding identifying information when conducting the investigation. The complainant is advised that preservation of anonymity may impede resolution of the grievance.
4. Investigation of a Grievance:
A. Guest Relations will coordinate the investigation, follow-up and resolution of grievances with the appropriate Department Manager(s).
B. Any situation the dangers the patient such as grievances related to allegations of perceived injury or abuse and/or neglect will be immediately addressed by the unit Manager, and/or Manager/Supervisor on Duty, and forwarded to Guest Relations /Quality Management/Risk Management will for confirmation of resolutions.
C. Any grievance concerning quality of care resulting in a negative patient outcome or the substantial risk of a negative outcome will be forwarded to Guest Relations/Quality Management/Risk Management as needed.
D. Guest Relations will review all grievances and forward the appropriate information and recommendations for resolution to Administration.
5. Response:
A. initial written response acknowledging grievance will be done within seven days by Guest Relations.
B. Guest Relations will notify the complainant of the actions taken on their behave to investigate the grievance, the results and date of completion of the investigation, and the person to contact if the complaint has any additional concerns. Resolution is expected within 30 days of receipt of grievance.
6. Performance Improvement:
A. A record of contact will be completed, tracked and trended for quarterly reporting via MIDAS.
B. The quarterly report will be presented to the Hospital Quality Improvement Committee for review. Any trends or patterns identified will be analyzed for opportunities for improvement in accordance with the Performance Improvement and Patient Safety Plan. " [Note: The health department telephone numbers are not current or correct].

2. On 11/21/2009, Patient Identifier (PI) #1 was admitted to the hospital with a diagnoses that include Altered Mental Status. The emergency department physician and the admitting physician's History and Physical examinations (dated 11/21/2009) noted no problems with the patient's range of motion or upper extremities.

3. On 11/24/2009, PI #1's right arm was found to be fractured and his right shoulder dislocated. This injury was noted three days after PI #1's admission to the hospital (on 11/21/2009).

4. On 11/24/09, PI #1's wife verbalized concerns and questioned how this injury occurred to more than one staff member. Hospital staff members, interviewed on January 5, 6, and 7, 2010, failed to document the wife's statements as a complaint or grievance, failed to thoroughly investigate the incident in a effort to determine possible cause(s) for the patient's injury, and failed to provide the wife (complainant) with written acknowledgment or follow-up, after the wife verbalized concerns and questions to more than one staff member.

5. Staff member failed to follow the hospital's current policy relative to the coordination, investigation, and documentation of PI #1's injury of unknown origin, and the hospital current policy has incorrect telephone number for reporting complaints to the Alabama Department of Public Health.

6. Refer to PI #1's medical record documentation and the interview documentation in citation A0123.

This citation written as a result of the investigation of complaint number AL00021780.

Based on hospital policy/procedures, medical record reviews, and interviews, staff members failed to follow the hospital's policy, when a family member verbalized concerns and questioned how Patient Identifier (PI) #1's arm was fractured arm and his shoulder dislocated after the patient was admitted to the hospital.
This deficient practice effected 1 of 10 sampled patients (PI #1).
Findings Include:

1. Hospital Policy:
The current policy entitled "Guestline Complaint/Grievance Resolution," dated as approved by the hospital's Quality Improvement Committee on 10/28/2008 includes:
"I. Purpose:
...strives to provide quality medical care in an atmosphere of care and concern for patients/family provides several mechanisms for patient/family members/surrogate decision makers/visitors. We encourage patients/ family members/surrogate decision makers/visitors to voice any concerns regarding their experience for quick and effective resolution.
II. POLICY:
...provides several mechanisms for the patient/ family members/surrogate decision makers/visitors to voice concerns or unmet needs. Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, unreasonable interruption of care, treatment and services. All employees and/or department management are available to assist those who express concerns. In addition, a guest relations representative is available to work on behave of the patient/family representative is available to work on behalf of the patient/family member/surrogate decision maker/visitor in resolving concerns or meeting needs.

Any employee receiving a complaint will immediately attempt to correct the problem. The concern will be referred to the appropriate manager. Guest Relations representative or Guest Line (by dialing...) if resolution is outside of his/her scope of responsibility, or cannot be resolved on the spot.
Guest Relations is available to any patient, family member, vendor, guest, community member, and visitor from 09:00 a.m.-9:00 p.m., Monday through Friday. During other times, complaints/grievances are to be directed to the Nursing Supervisor or through the Guest Line.

Patients may file grievances with the State of Alabama Department of Public Health by calling...or in writing...If they have a complaint regarding quality of care, disagreement with a coverage decision, or they wish to appeal a premature discharge. A complaint can be submitted by calling...
III. PROCEDURE:
1. Information:
Upon admission, all patients receive written information explaining their right to report any concern or dissatisfaction/complaint/grievance in the Guest Information Brochure and the admission ' s memorandum. " Your Rights and Responsibilities and Our Organization Ethics. " Medicare patients receive an additional instruction material entitled, " An Important Message from Medicare about Your rights. " Information is also posted throughout waiting areas and in patient rooms.
2. Complaint/Concern or Dissatisfaction is defined as: a verbal complaint that can be resolved at the time of complaint by staff present.
a. A complaint/concern/dissatisfaction can be filed with any hospital employee, volunteer, physician.
B. A complaint/concern/satisfaction can be resolved to the customer ' s satisfaction by implementing a change or response in a timely manner.
C. Employees receive training to encourage and teach our service recovery philosophy and methodology.
3. Grievance is defined as: a written or verbal complaint that cannot be resolved at time of complaint by staff present.
A. Guest Relations/Quality Management/Risk Management will be responsible for responding to formal grievances.
B. Guest Relations/Quality Management/Risk Management will act as liaison between the medical/hospital staff, administration, and the customers.
C. If the complainant wishes to verbally state their grievance, needed information will be documented.
D. Grievances made by telephone call or letter from discharged patients will be forwarded to Guest Relations.
E. If it is determined that anonymity is important, or if the complainant requests it, the anonymity of the patient will be provided for by excluding identifying information when conducting the investigation. The complainant is advised that preservation of anonymity may impede resolution of the grievance.
4. Investigation of a Grievance:
A. Guest Relations will coordinate the investigation, follow-up and resolution of grievances with the appropriate Department Manager(s).
B. Any situation the dangers the patient such as grievances related to allegations of perceived injury or abuse and/or neglect will be immediately addressed by the unit Manager, and/or Manager/Supervisor on Duty, and forwarded to Guest Relations /Quality Management/Risk Management will for confirmation of resolutions.
C. Any grievance concerning quality of care resulting in a negative patient outcome or the substantial risk of a negative outcome will be forwarded to Guest Relations/Quality Management/Risk Management as needed.
D. Guest Relations will review all grievances and forward the appropriate information and recommendations for resolution to Administration.
5. Response:
A. initial written response acknowledging grievance will be done within seven days by Guest Relations.
B. Guest Relations will notify the complainant of the actions taken on their behalf to investigate the grievance, the results and date of completion of the investigation, and the person to contact if the complaint has any additional concerns. Resolution is expected within 30 days of receipt of grievance.
6. Performance Improvement:
A. A record of contact will be completed, tracked and trended for quarterly reporting via MIDAS.
B. The quarterly report will be presented to the Hospital Quality Improvement Committee for review. Any trends or patterns identified will be analyzed for opportunities for improvement in accordance with the Performance Improvement and Patient Safety Plan. "

2. Patient Identifier (PI) #1 was admitted to the hospital on 11/21/2009 from the emergency department (ED).
The ED physician's documentation includes: "HISTORY OF PRESENT ILLNESS...Chief Complaint: DECREASED MENTAL STATUS and CHANGE MENTAL STATUS: Arrived by EMS...pt [patient]...usually verbal now non verbal with response to pain stimuli)...has had difficulty walking. No weakness, numbness of recent fall...Back: Normal inspection...Skin warm and dry. Normal skin color...Extremities exhibit normal ROM. No lower extremity edema...moves upper and lower ext..."

The admitting Primary physician's 11/21/2009 History and Physical noted PI #1's : "...Extremities: Exhibit normal range of motion with no lower extremity cyanosis, clubbing or edema..."

On 11/21/2009 evening and night shift nurse noted no pain or injury to PI #1's arm in the Patient Assessment/Care Record, but documentation in the "Focus Notes" from thie assessment include:
0100: (? 11/22/09) include: "...seizure...Pt [patient/PI #1] shaking all over his body. Pt not responding to stimuli & spitting... lasting 30 seconds..."
0105: "...seizure Notified CRNP of pt having a seizure &..."

On 11/22/2009 08:10 AM, the nurses "Patient Assessment/Care Record" noted PI #1's apical, radial, and Dorsalis Pedis pulses left and right present with no edema noted. No bruising or injury to the patient's extremities are documented.

On 11/23/2009 08:00 AM, the nurses "Patient Assessment/Care Record" noted PI #1 had pitting edema in his right upper arm. The nurses "Focus Notes" from this assessment include:
11:00:...given "Xanax"..."1200:...No improvement."
2000:...PI #1's left arm IV "infiltrated"...IV "restarted in the right arm"... patient "combative."

On 11/24/2009 09:30 PM, "Patient Assessment/Care Record" noted PI #1 had non-pitting edema in his right arm and the "Focus Notes" include:
1610: "(R) [right] arm...Spoke to Dr...reported (R) arm orders rec'd [received].
1700: "Vasc [vascular]...Attempted to do doppler but vasc tech reported combativeness and pain sent to x-ray."
1945: "MD[medical doctor]...Dr...here to see -examine with attention to (R) arm..."
2230: "Pain...Routine...given for pain in right arm..."

The 11/25/2009 07:45 "Patient Assessment/Care Record" documented that PI #1's right arm was swollen and "purplish."
The "Focus Notes" include:
1700: "...Should [shoulder?] immobilizer placed on to immobilize RT shoulder..."

On 11/25/2009 orthopedic physician's noted PI #1 had a fracture of the right humerus and posterior head "d/c" [dislocation].

Interviews:
On 1/5/2010 at 10:05 AM, the day shift registered nurse (RN) assigned to the PI #1 on 11/23/2009 and 11/24/2009 was interviewed. This nurse recalled the night nurse reporting (during shift change) that PI #1 had some bruising and that PI #1 was to have vascular studies but these vascular tests were not done due to PI #1 having pain in his arm. This nurse recalled PI #1's right humerus had yellowish discoloration areas and the areas under the arm were dark purple in color. This nurse did not document her observations in the Focus Notes and stated she had no knowledge of when or how the bruising on PI #1's right arm first occurred.

On 1/5/2010 at 10:05 AM, the RN Team Leader was interviewed. This nurse recalled being informed (by the day shift nurse) that PI #1's right arm was bruised and swollen. The Team Lead nurse did not physically assess PI #1 but recalled seeing purplish bruising on PI #1's right arm. This nurse reported she did not talk with PI #1, his wife, or staff providing care to the patient relative to possible causes of the injury.

On 1/5/2010 at 11:40 AM and 1:00 PM, the two Vascular Technicians (on duty 11/23/2009 and 11/24/2009) were interviewed. Both recalled trying to perform vascular studies on PI # 1 and both said PI #1 was confused, moving about and hollering when they tried to do the test. The patient reportedly refused to let the technicians touch his arm, so he (PI #1) was returned to his room without the test being done. The vascular technicians stated they told the nurses on the hall that the test was not done and about PI #1's behavior. Both denied trying to hold PI #1 down for these tests.

On 1/6/2010 at 10:00 AM, the House Supervisor recalled talking to the wife of PI# 1. This nurse recalled PI #1's wife saying PI #1's right arm was broken after his admission to the hospital and she (wife) wanted to know how this happened. The House Supervisor recalled going to PI #1's room and taking photos of PI #1. At the time of the photos, PI # 1 was had an immobilizer on his [PI #1's] right arm.The House Supervisor stated he asked the nurse on duty about falls, but he did not document his conversation about the falls, and was not with the investigation or questioning of staff relative to the patient's injury. The House Supervisor stated after taking the photos of PI #1's injury, a QAR [Quality Assurance Report] was filled out and turned the report over to Risk Management. This is the initial QAR report relating to this injury of unknown origin and this report is dated 11/27/2009, four days after staff and physician's noted the patient's injuries.

On 1/5/2010 at 9:10 AM, the Unit Manager assigned to PI #1's unit reported: "...I spoke to Mrs...[PI #1's wife] about her husbands bruised and fractured shoulder on a Monday, the week after Thanksgiving..." This was 3-4 days after the injury is documented by other hospital staff members. This nurse noted: "...He complaint was that Mr. [PI #1] suffered an injury while in our facilty. After interviewing the wife of said patient, i reviewed the chart, interviewed staff, notified our Director...and spoke to ...I spoke to Mrs. [patient's wife] again to ensure that the care her husband was receiving was to her satisfaction, she said it was. I saw that the appropriate test s and physicians were involved in the patient's care...I did not physically assess this patient..." This witness noted that PI #1's wife "...offered her thoughts freely. She believed that Mr...[PI #1] was either held down against his will...or he fell out of bed..."
When asked if he [Unit Manager] documented PI #1's wife's statements as a complaint, documented the alleged staff interviews, or documented his observations of PI #1, the Unit Manager replied, "No."

On 1/6/2010 the Guest Relations Manager and Risk Manger denied conducting an investigation to determine possible causes for the injury to PI #1's arm and shoulder. Hospital staff did not respond to the patient's wife in writing after the initial concern was voiced, as directed in the facility policy.

This citation written as a result of the investigation of complaint number AL00021780.