HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:
1. Initiation of grievance process for one (01/06/22 grievance) of one grievances
2. Recognition of grievance for one (01/06/22 grievance) of one grievances
3. Policy review for one (Grievance policy) of one policies
4. Knowledge of facility organization for one (Rolling Hills Hospital) of one facilities

This failed practice has the likelihood to result in concerns of patients or patient representatives going unaddressed, thereby impeding their rights as patients.

Based on record review and interview, the hospital failed to ensure:
1. Initiation of grievance process for one (01/06/22 grievance) of one grievances
2. Recognition of grievance for one (01/06/22 grievance) of one grievances
3. Policy review for one (Grievance policy) of one policies
4. Knowledge of facility organization for one (Rolling Hills Hospital) of one facilities

This failed practice has the likelihood to result in concerns of patients or patient representatives going unaddressed, thereby impeding their rights as patients.

Review of policy titled "Patient Rights and Responsibilities" read in part, "In order to respect, protect, and promote patient rights, Rolling Hills Hospital employees and members of the Medical Staff shall: ...respect the patient's and his or her family's right to have complaints reviewed by the Rolling Hills Hospital leadership."

Review of policy titled "Grievance Policy" read in part, "Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect. ...STAFF PROCEDURE: Staff present who receive a grievance/concern ...will acknowledge receipt of the grievance/concern by documenting the time and date of the grievance ...If grievances are not resolved within seven (7) days, patient will be notified that Patient Advocate is still processing the grievance and provided the expected date of resolution in 30 days."

Review of policy titled "Policy Development" read in part, "Each policy and procedure are reviewed at least annually ....The Quality Council is responsible for managing the annual review of Policies and Procedures."

Initiation of Grievance Process

Review of the grievance log showed no entries for the month of January 2022 and staff had received a call from a patient's family in January alleging abuse.

On 01/12/22 from 12:00 PM to approximately 1:22 PM, Staff A stated the following:
1. On 01/05/22, a healthcare facility spoke to Staff A on the phone stating they had admitted a discharged Rolling Hills patient with bruises and who had possibly been raped.
2. On 01/06/22, the same patient's family member spoke to Staff A on the phone stating they wanted to make a complaint related to abuse.
3. The 01/06/22 phone call about abuse was not a grievance.

On 01/13/22 at approximately 10:48 AM, Staff A reviewed the grievance policy and stated the following:
1. No written response had been provided and no phone call had been made to the patient's family member regarding the abuse complaint. (Eight days after family notified facility)
2. The Patient Advocate should have been notified to start the grievance process and was not.

Recognition of Grievance

On 01/12/22 from 12:00 PM to 1:29 PM Staff A stated the following:
1. A complaint was when a patient or patient representative contacted the corporate complaint hotline.
2. He or she was not 100% positive what a grievance was.
3. He or she did not know how a complaint or grievance was defined in the facility policy.
4. There had been no grievances from 11/01/21 to present.

On 01/13/22 at approximately 10:48 AM, Staff A reviewed the grievance policy and stated the phone call he or she received on 01/06/22 regarding abuse should have been treated as a grievance.

Policy Review

Review of policy titled "Grievance Policy" did not show a policy review date for 2021 and documented a policy review date of December 2016.

On 01/13/22 at 11:40 AM, Staff A reviewed the grievance policy and the policy development policy and stated the following:
1. He or she did not know why the grievance policy had not been reviewed since 2016.
2. The Quality Council was responsible to ensure all facility policies were reviewed annually.

Facility Organization

Review of a document titled "Rolling Hills Hospital Organizational Chart" showed the Patient Advocate position reported to Risk Management.

On 01/12/22 at approximately 1:29 PM, Staff A stated the following:
1. The Patient Advocate reported to the Chief Executive Officer.
2. The provided facility organizational chart showed the Patient Advocate reported to Risk Management, but was not correct.

On 01/12/22 at 2:32 PM, Staff H stated the Patient Advocate reported to Risk Management.

On 01/13/22 at approximately 5:00 PM, during the exit conference, Staff C stated the facility organizational chart provided to the surveyor was incorrect and provided another one.

In review of the latter facility organizational chart, it was not distinguishable whether the Patient Advocate reported to Risk Management or the Chief Executive Officer.

Based on record review and interview, the hospital failed to ensure monitoring of skin alteration for three (Patients #1, #3, #4) of five patients.

This failed practice has the likelihood to result in delayed or no prevention of new skin alterations, delayed recognition of medical condition and delayed receipt of medical treatment.

Review of policy #218: Skin Assessment read in part, "All patients shall receive a daily skin reassessment, which shall be documented on the Daily Nurse Reassessment Progress Note. Patients with significant skin conditions ...shall be documented by a nurse ...until the bruising or wound has resolved ...The nurse shall: ...For wounds or bruising: pictures will be taken ....Carefully note changes in color, shape, and size, and other details....Risk Manager or Designee: For bruises and wounds that develop during a patient's stay, which are reported on an incident report form, take photographs of all affected areas of the patient's body."

Patient #1

Review of the medical record for Patient #1 showed no photographs of wounds and showed no color, shape, size or details of the wounds described in the following written documentation:
--Internal document dated 12/07/21 showed the patient had dark bruising to left inner thigh and calf.
--"Nursing Reassessment" document dated 01/04/22 at 9:32 AM showed scattered, healing bruises to the front of both legs and a stage two decubitus wound at buttocks.
--Internal document dated 01/06/22 showed that on the morning of 01/04/22, the patient had bruises on both arms, on top of one breast, between the thighs, around the knee area, and on the back.

On 01/13/22 at 3:00 PM, Staff C reviewed the medical record for Patient #1 and reviewed the skin assessment policy and stated nursing should have taken a picture of the patient's bruises.

On 01/13/22 at 3:17 PM, Staff A stated he or she did not take any pictures of the patient's bruises and should have.

Patient #3

Review of the medical record for Patient #3 showed no photographs of the wound described in the following written documentation:
--Internal document dated 11/28/21 showed the patient had a laceration to the right lower leg.

Patient #4

Review of the medical record for Patient #4 showed no photographs of wounds and showed no color, shape, size or details of the wounds described in the following written documentation:
--Internal document dated 12/07/21 showed the patient with an abrasion to the right forehead and right knee.
--"Nursing Reassessment" document dated 12/08/21 showed the patient had scattered bruises on both hands and a red forearm.

On 01/13/21 at 3:27 PM, Staff F reviewed the medical records of Patients #3 and #4 and stated there were no photographs of wounds.