HospitalInspections.org

Based on interview, review of the facility's grievance log and grievance policy it was determined the facility failed to provide written notice of its resolution of a grievance for one of three sampled patients (that voiced a complaint) out of a total of ten sampled patients. Patient # 1's family representative notified the facility of her concerns regarding quality of care issues. However, the facility failed to forward the grievance to the appropriate administration staff resulting in no resolution of the grievance. The facility failed to provide written notice of the steps taken to resolve the patient's concerns.

The findings include:

Review of facility policy Patient Complaint/Grievance Process, revised 02/2012, revealed a patient has the right to express concerns and expect resolution in a timely manner. The patient's/patient representative's complaint would be reviewed, investigated, and resolved within a reasonable time frame. The hospital will maintain a procedure for systematic notification in and resolution of complaints and grievances, including documentation of results. Patients/patient representative are informed of the complaint/grievance process through written materials, such as Patient Handbook, Patient information guide, and admission packet. Posted ASAP posters and brochures will be placed in readily accessible locations. In addition, the facility has a ASAP hotline. The policy outlines a 4-step process for completion of the grievance form with step-4 providing a written response to the complainant within seven (7) days. The written response would include steps taken to investigate the grievance and the results of the grievance process. Complaints/Grievances are entered on the Complaint/Grievance log. The policy's definition of "Grievance": a written or verbal complaint by a patient or patient's representative regarding any aspect of the patient's care, account or other aspect of the stay that cannot be resolved on the spot by the staff present.


Interview with Patient #1, on 03/26/12 at 4:10 PM and 03/27/12 at 5:15 PM, revealed the patient had concerns regarding the call light being answered promptly. The patient revealed she/he is able to speak now, but that was not the case before. Upon admission the patient was on a ventilator and unable to voice concerns. The patient stated whenever she/he would activate the call light it would take staff a long time to respond. The patient revealed she/he had to call a family member for help one night (communicated by pressing the telephone buttons (one=yes, two=no). The family member called the nurses' station and requested the staff to check on the patient. Another incident, the patient stated she/he was sitting up in a chair when the trachea cannual came out and fell onto the floor. Because the patient's trach was not plugged at the time, the patient could not call out for help. The patient activated the call light but it took a long time for staff to respond. The patient stated she/he was afraid. The patient stated a 30 minute wait for assistance is not usual and it has been longer. "I feel sorry for those patients that don't have anyone to check on them."

Interview with Patient #1's sister, on 03/28/12 at 10:45 AM, revealed she received a telephone call one night in February 2012 from the patient. The patient has a cell phone. When she answered the call, nobody said anything so she knew it was Patient #1. The sister revealed the patient and she had already established a non-verbal system to communicate whenever the patient needed to talk with her. The sister stated she called the nurses' station and requested the staff go check on the patient because the call light had not been answered.

The same day, the sister stated she witnessed a nurse being rough with the patient during removal of an indwelling catheter. She indicated the nurse jerked the catheter out and washed the patient roughly. The sister stated she was upset and reported the incident to the charge nurse but she had not heard anything back from the hospital; however, that nurse has not cared for this patient since she voiced the complaint. She stated she spoke with the 5th floor nurse manager the next day and told her about the call lights not being answered promply. She had not received any written response nor had anyone from the hospital spoken with her regarding her concerns. The sister revealed she had witnessed staff coming into the room, turning off the call light, and telling the patient the nurse would be with her shortly. She stated the nurse did not come.

Interview with the 5th floor nurse manager, on 03/28/12 at 11:10 AM, revealed she recalled speaking with Patient #1's sister regarding the call light response and baths not being provided. She recalled the sister was very angry. She stated the sister told her the patient kept calling her at home because the call light was not being answered. The nurse manager validated with the staff that the sister would call the nurses' station and request the staff to check on the patient. The nurse manager said she wrote the concerns down and reported the concerns to her supervisor. The staff was immediately spoken to and re-education was provided on-the-spot. The sister also reported a nurse was rough with the patient during a procedure. "I told the sister I would take care of her concerns." She indicated she had filled out a Grievance complaint form. However, review of the Complaint/Grievance log revealed no information regarding Patient #1 had been included.

On 03/28/12 at 1:00 PM, the nurse manager revealed she could not find the grievance form and stated she had not notified the Director of Quality Management (DQM) as instructed in the Grievance policy. The manager stated she had not forward the information to anyone. "I know how to complete the Grievance form and I thought I had but I can't find it." The nurse manager indicated she failed to notify the DQM because the DQM always calls to the units and asks when the grievance forms will be complete.

Interview with the Director of Quality Management, on 03/28/12 at 1:20 PM, revealed she had not received any notification (phone or email) of a grievance regarding Patient #1. She stated she searched her paperwork and did not find any evidence the nurse manager had forwarded the information to her. She stated all unit managers have been trained on the grievance policy and the CoP (Condition of Participation), including how to complete the forms. It is suppose to be reported to me so I can monitor for completion and send a written response to the person who voiced the complaint.

Interview with the CEO (administrator) of the hospital, on 03/28/12 at 1:50 PM during the exit conference, revealed he was disappointed the complaint/grievance policy and procedure was not followed and the written response was not provided to the person who voiced the complaint. He stated the staff had been trained and the DQM monitored for compliance very closely. Patient satisfaction is very important and we strive to meet the patients' needs.