HospitalInspections.org

Based on document review and interviews, the Facility failed to create a procedure to handle patient complaints and grievances in a manner that was consistent with established regulations.

This failure created the potential for patient complaints and grievances to be unaddressed and unresolved.

FINDINGS:

1.The facility failed to properly document and track actions taken to address patient complaints.

a) On 7/31/13 at 1:00 p.m., an interview was conducted with the facility's Patient Advocate. The Patient Advocate stated s/he had been informed by the Chief Executive Officer (CEO) not to call patient #13 back. The CEO told the Patient Advocate that s/he would take care of the final phone call and resolution.

b) On 7/31/12 at 2:00 p.m., an interview was conducted with the facility's CEO regarding the follow-up of patient complaints. The CEO stated s/he had called patient #13 back to follow up on a complaint. When asked if there was formal documentation of complaint resolution or escalation of a complaint to a grievance sent to the state, s/he stated there was no formal documentation.The CEO stated s/he did not offer to forward the complaint to the state, nor did s/he send a follow up or conclusion letter to the patient.

c) On 07/31/13 at 3:00 p.m., the facility's policy titled "Patient Complaints, Handling of" was reviewed. The policy stated "If the patient or his/her designee is not satisfied with the report from the Administrator the Administration will be informed. The patient will be informed that issue can be referred to the executive Director of the Colorado Department of Health, in writing, by the Patient Representative if requested or directly by the patient." The facility's Patient Advocate verified this was the current policy and that no letter had been sent to the patient or the state.

Based on staff interview and record review the facility failed to maintain a safe environment to protect the health and safety of patients.

This failure created the potential for patient injury.

Findings

1. The facility failed to ensure that patient #13 had access to a call bell for 30 minutes.

a) On 07/31/13 at 12:40 p.m., an interview with the facility's Patient Representative was conducted. the Patient Representative stated that s/he had received a complaint from Patient #13 stating that Patient #13 did not have a call bell during a visit to the facility's Emergency Department.

b) On 07/31/13 at 1:20 p.m., an interview with the Emergency Room Director was conducted. S/he stated that s/he had received two phone calls form the police department 20 minutes apart stating that Patient #13 had called 911 claiming that she did not have a call bell. After the second call from the police department the Emergency Room Director went in to Patient #13's room and the call bell had not been accessible to the patient for 30 minutes. The patient had been given multiple narcotics increasing the risk for fall. At that time the Emergency Room Director gave Patient #13 the call bell.