HospitalInspections.org

Based on document review, interview and review of the facility's Policy & Procedures (P & P), the facility failed to follow their own P & P for 1 of 1 patient (Patient #1) grievances reviewed, by not ensuring a patient grievance was investigated and resolved within the time frames set forth by the facility.

Findings:

Interview with the Patient Representative on 7/8/10 at 5:00 pm revealed the patient #1 called her 2 days after discharge and told her about the experience he/she recently had on the Labor and Delivery (L & D) unit on 6/6/10. Further interview revealed the Patient Representative took down the information and forwarded it to the Quality Department, who is still reviewing the case. Further interview revealed she sent a letter to the patient on 6/11/10.

Review of the letter dated 6/11/10 revealed "the issues you have raised have been forwarded for further review and you will receive a letter at the conclusion of the review."

Review of the facility's P & P for Patient and Family Complaints and Grievances revealed the hospital shall review, investigate, and resolve patient grievances within a reasonable time frame. Although every effort should be made to resolve the patient grievance with 7 days, in the event it will not be resolved in 7 days, the hospital should inform the patient that the hospital is still working to resolve the grievance and will follow up with a written response within 30 days. Further review of the P&P revealed the written response to the patient shall:

be sent as soon as possible, but not more than 30 days from receipt of the patient grievance, address each grievance expressed by the patient, provide the patient written notice of the hospital's findings.

Interview with patient #1 on 7/8/10 at 4:13 PM revealed the only letter he/she has received is the one dated 6/11/10 by the Patient Representative.

The date this survey was conducted was 30 days since the patient's grievance was taken.

Based on record review and interview, the facility failed to provide 1 of 1 (Patient #1) patients in the Labor and Delivery (L&D) Unit with medications in a timely manner.

Findings:


Review of patient #1's record revealed the patient was admitted in to the L&D on 6/6/10. Review of the L & D triage orders, dated 6/6/10 at 8:50 am, revealed orders for Dilaudid 4 milligrams (mg) intravenous (IV) to be administered, however, review of the OB triage flow record reveals documentation that the first dose of Dilaudid was not administered until 11:40 am, 3 hours after the patient arrived on the unit.
Interview with L & D staff, on 7/8/10 beginning at 6:00 pm, revealed statements that although it is documented on the L & D triage orders that the Dilaudid was ordered at 8:50 am, it was actually ordered at approximately 11:35 am because she administered it at 11:40 am. Further interview with L & D staff revealed each time the pain medication was ordered, it was administered to the patient within 5 minutes of receiving the order. The staff also stated the 2 physician's on the unit were approached several times requesting pain medication as the patient was "in a lot of pain."