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Based on policy review, grievance file review, and staff interview, the hospital failed to provide a patient with a written acknowledgement and/or follow-up letter to a patient's grievance per facility policy for 1 of 2 sampled grievance files (Patient #10).

The findings include:

Review of current hospital policy "Grievance Management Policy" effective date: August 23, 2011, revealed "...4. Upon receipt of the patient grievance,....Within two business days, the (Health System Name) Service Excellence Department will provide the patient with a written acknowledgement that the grievance has been received and is being investigated. ...5. Within seven business days, the patient will be sent a follow-up letter from the assigned department leader addressing a resolution or notifying the patient that further investigation is required and notifying the patient of an expected follow-up time to address the resolution. All grievances will be resolved as soon as possible with a goal of resolution within seven days, and in no even should take longer than 30 days to resolve. The patient will be kept informed of the progress on a weekly basis in the form of verbal and/or written communication.

Grievance file review on 03/21/2012 for Patient #10 revealed on 03/06/2012 the patient's representative (son) filed a grievance in person at Hospital B (another hospital within the same healthcare system as Hospital A) referencing quality of care issues during his mother's hospitalization at Hospital A. File review revealed the grievance was forwarded via electronic mail to multiple administrative management staff at Hospital A on 03/06/2012 at 1849 for review/investigation/resolution. File review failed to reveal any available documentation of a written acknowledgement sent to the patient and/or patient's representative, that the grievance had been received and was being investigated. File review failed to reveal within seven business days, the patient and/or patient's representative was sent a follow-up letter from the assigned department leader addressing a resolution or notifying the patient and/or patient's representative that further investigation was required; and of an expected follow-up time to address the resolution as of 03/21/2012 (15 days later).

Interview on 03/21/2012 at 1650 with the Director of Organization Development and Service Excellence revealed the Director is over the grievance process for the Health System which includes Hospital A. Interview revealed when Patient #10's representative filed a grievance on 03/06/2012, the Service Excellence staff at Hospital B shared responsibility for Hospital A and Hospital B. Interview revealed now each hospital has its own service excellence staff member to handle grievances. Interview revealed there was no initial acknowledgement letter sent to Patient #10 and/or their representative, that the grievance had been received and was being investigated. Interview revealed there was no written follow-up letter sent to Patient #10 and/or their representative within 7 business days from the assigned department leader addressing a resolution or notifying the patient and/or patient's representative that further investigation was required; and of an expected follow-up time to address the resolution as of 03/21/2012. Interview revealed the grievance file was considered open. Interview revealed "I will take ownership that we did not write any letters." Interview revealed "we were trying to do good, just didn't follow our policy." Interview confirmed the hospital staff failed to follow the hospital's grievance management policy.

Based on hospital policy and procedure reviews, observations during tours, and staff interviews the nursing staff failed to ensure medications stored in crash carts were secured, locked, and not accessible to patients/visitors/family members when not in use by authorized staff within patient care areas.

The findings include:

Review of current hospital policy "Crash Cart Maintenance" approved 10/08/2009, revealed "...Crash Cart Check ...Verify that: a. The cart/box is locked. ..."

Review of current hospital policy "Infection Control Policy Nursing Services" approved 06/22/2010, revealed "...7. PATIENT SUPPLIES IN CARTS LOCATED IN PATIENT ROOMS ...7) Drawers should always be locked when not in room."

Observation during tour on 03/20/2012 at 1015 of the emergency department revealed an adult crash cart being stored in ED Bed #1. Observation revealed the drawer containing emergency medications was unsecured and able to be opened by the surveyor without difficulty. Further observation revealed all other drawers on the crash cart were secured and unable to be opened. Observation revealed the crash cart was not in use or being directly supervised by authorized staff at the time of observation. Observation revealed a patient and family member/visitor located adjacent to Bed #1 in Bed #2 within visualization of the crash cart. Interview during tour with nursing management staff revealed all drawers on the crash cart should be secured when not in use. Interview revealed only authorized personnel should have access to the medications in the crash cart. Interview confirmed the nursing staff failed to follow hospital policy.

Based on hospital policy and procedure reviews, observations during tour, and staff interview, the hospital's staff failed to ensure emergency respiratory boxes were locked; supply carts were secured; intravenous fluids and irrigation solutions stored in warming cabinets were not expired; and the physical environment was maintained in a manner to ensure patient safety.

The findings include:

1. Review of current hospital policy "Crash Cart Maintenance" approved 10/08/2009, revealed "Policy: ...4. Every time a....Airway Box is opened the contents must be verified and a new lock issued. ...Crash Cart Check Check the Cart to ensure all supplies stored on top of the unit are present and locks are intact. ...Verify that: ...d. The airway box is present and locked...."

Observation during tour on 03/20/2012 at 1015 of the emergency department revealed a Respiratory Box being stored ontop of Cart #15 located between ED Bed #1 and Bed #2. Observation revealed the box contained respiratory supplies/equipment for emergency intubation. Observation revealed the security lock #5473865 was not intact. Observation revealed the box was able to be opened by the surveyor without difficulty. Observation revealed the box was not in use or being directly supervised by staff at the time of observation. Interview during tour with nursing management staff revealed the respiratory box should be secured when not in use with a security lock. Interview revealed the nursing staff did not know when the box had been opened or if any emergency supplies had been removed. Interview confirmed the nursing staff failed to follow hospital policy.

2. Review of current hospital policy "Infection Control Policy Nursing Services" approved 06/22/2010, revealed "...7. PATIENT SUPPLIES IN CARTS LOCATED IN PATIENT ROOMS ...7) Drawers should always be locked when not in room."

Observation during tour on 03/20/2012 at 1015 of the emergency department revealed a blue cart being stored in ED Bed #1. Observation revealed the cart was used to store patient care supplies. Observation revealed drawer #3 contained intravenous angiocaths/jelcos ("sharps") used to obtain intravenous access on patients. Observation revealed the other drawers on the cart containing patient care supplies were also unsecured and able to be opened by the surveyor without difficulty. Observation revealed the blue supply cart was not in use or being directly supervised by nursing staff at the time of observation. Observation revealed a patient and family member/visitor located adjacent to Bed #1 in Bed #2 within visualization of the blue supply cart. Interview during tour with nursing management staff revealed all drawers on the blue supply cart should be secured when not in use. Interview revealed only nursing staff should have access to the supplies stored in the cart. Interview confirmed the nursing staff failed to follow hospital policy.

3. Review of current hospital "Temperature Monitoring Record Warmer # [Hospital Name] ED (hand written)" for "Month: March (hand written) Year: 2012 (hand written)" revealed "Acceptable Temperature Ranges: Solution Warmers: IV (intravenous) bags may be stored by temperatures NOT to exceed 104 (degrees) F (Fahrenheit) for no longer than 14 days and pour bottles may be stored at temperatures NOT to exceed 104 F for no longer than 30 days...."

Observation during tour on 03/20/2012 at 1030 of the emergency department revealed a two (2) compartment warming cabinet in use. Observation revealed the temperature of the upper compartment was 100 degrees F (Fahrenheit). Observation revealed inside the upper compartment, (4) four 250 milliliter (ml) pour bottles of 0.9% sodium chloride were being stored. Observation of the 4 bottles revealed each bottle had a handwritten expiration date of 03/11 (9 days expired) on the bottle's label. Further observation revealed (2) two 1000 ml bags of IV Lactated Ringers (LR) solution being stored. Observation of the 2 bags revealed each bag had a handwritten expiration date of 03/07 (13 days expired) on the bag's label. Interview during tour with nursing management staff revealed the nursing staff are supposed to handwrite on the label the expiration date of the the IV solutions and pour bottle solutions when they are placed into the warming cabinet. Interview revealed IV solutions expire after 14 days and pour bottle solutions expire after 30 days. Interview confirmed the 4 pour bottles of saline solution and 2 bags of IV LR solution had expired. Interview confirmed the nursing staff failed to follow hospital procedures.

4. Observation during tour on 03/20/2012 at 1045 of the emergency department revealed ED Rooms 9, 11, and 12 used for patient care. Observation revealed within each room, one or more wall surfaces with multiple areas of sheetrock damage at/or about chair rail height. Interview during tour with nursing management staff confirmed the presence of sheetrock damage and that it was a safety and infection control concern.

NC00079333
NC00076296