HospitalInspections.org

Based on interview and record review the facility failed to collect complaint data; and failed to use the data collected to identify opportunities for improvement and changes that will lead to improvement.

Findings Include:

During an interview on 3/15/16 at 3:20 p.m. in the conference room, Staff #1, Director of Nursing, stated, "I don't document patient complaints." Staff #1 stated, "I'm not aware of a formal complaint form, I will get pieces of paper under my door sometimes." Staff #1 was shown a previous complaint, written on a plain piece of paper, with a concern regarding how a staff person talks to the patients. When asked if these concerns are tracked and looked for trends for use in the Quality Assurance Program, Staff #1 stated, "No, they are just fixed." "We don ' t record how it was corrected or who is going to correct the concern."

During an interview on 3/15/16 at 3:20 p.m. in the conference room, Staff #1, Director of Nursing confirmed the findings.