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Based on review of hospital policy, occurrence and grievance file review, medical record review and staff interview, the hospital staff failed to provide a written letter of resolution for 2 of 2 grievances reviewed. (Pt #3)
The findings include:
Review of the hospital's policy "Complaint/Grievance Procedures for Patients" last revised date of 08/07/2012 revealed "...Grievance - a formal or informal written or verbal complaint that cannot be resolved promptly on the spot by staff present, or: the patient or authorized representative requests the complaint be handled as a formal complaint or grievance or when the patient or authorized representative requests verbal or written follow-up from (name of facility) and all allegations of abuse, neglect, injury,...should be reported immediately to management and treated as a grievance ...ii. B) Complete a thorough investigation with input from the complainant as needed c) review all appropriate documentation d) interview all involved parties e) determine which actions, if any, can be taken to resolve grievance ...C. Written responses: 1. letters with the results of investigation must include...b. a description of the steps taken on behalf of the patient to investigate the grievance...D. Timelines: 1. As soon as reasonable: 3. Five (5) business days: Acknowledge written complaints from patients who have been discharged from care. 5. Twenty (20) business days: a. written responses completed and sent".
Closed medical record review on 04/22/2014 of Patient #3 revealed a 30 year old male admitted on 07/18/2013 with Gunshot wound with injury to C5 (cervical spine) and C6 resulting in quadriplegia (paralysis all four extremities). Review revealed the patient was transferred from the acute care to the facility's Rehabilitation Unit on 07/29/2013. Continued review revealed a discharge date of 09/18/2013.
Continued review revealed Pt #3 was readmitted on 01/14/2014 with a diagnosis of deep vein thrombosis (DVT) of the left lower extremity, Urinary tract infections, History of C5 quadriplegia, Stage I and II decubitus ulcers and fever. Continued review revealed a discharge date of 01/23/2014
1. On 04/23/2014 review of the "Complaint/Grievance Tracking Form" revealed a complaint received on 08/10/2013 at 0230 for Pt. #3. Review of the form revealed "Patient and his mother report extended wait time when they called for assistance. Questionable default in call system. Special device 'puffer' (call bell that can be used with the mouth) system designed to assist quad patients...Action Taken: Spoke to mother on phone 08/12 (2 days after receipt of the complaint) met with patient on 08/14 (4 days after receipt of the complaint)..." Continued review revealed typed notes by the Unit Nurse Manager dated 08/12 (2 days after receipt of the complaint).
Continued review revealed a second typed letter signed by the Director of Rehabilitation dated 08/19/2013. Review of the letter revealed "Received a telephone call from patient's mother, (name), on Wednesday, 08/14 (four days after initial complaint)." Continued review revealed multiple patient care complaints "...1. the patient has a hard time with secretions and woke up with the need to ... cough on Friday night 08/09. The mother rang the call bell and no one came ...2. On Sunday, 08/11 the mother entered the patient's room to find her son 'red-faced' and in pain. He reported a 'substitute nurse' came in and tried to reposition him during his bowel training program. He reported the nurse pulled his arm and 'it popped' ... " Continued review revealed two additional complaints related to a catheterization (tube inserted into bladder) on 08/12 and a complaint related to the staff's behavior.
On 04/23/2014 at 1327 interview with the Rehabiliatation Unit Nurse Manager revealed "We should have followed our grievance policy and formulated a response to the patient's mother." Interview confirmed the hospital staff failed to provide a written letter of resolution for a grievance.
On 04/23/2014 at 1426 interview with the Director of Rehabilitation Services revealed "I did not treat this complaint as a grievance and did not send a letter of resolution." Interview confirmed the hospital staff failed to provide a written letter of resolution for a grievance.
On 04/24/2014 at 0816 interview with the Director of Patient Safety and Risk Management revealed "anything that requires investigation of a complaint or follow-up or any allegation of injury, abuse, and neglect is automatically a grievance. There was no letter of resolution mailed for this grievance." Interview confirmed the hospital staff failed to provide a written letter of resolution for a grievance.
2. Review of "Occurrence" document #201467 "create time" of 01/28/2014 at 1749 for Pt #3 revealed a complaint received from Pt #3's mother on 01/28/2014. Review of the complaint revealed "received call from patient's mother (name and phone number) who is concerned that patient (name) (Pt #3) was discharged too early. Patient was discharge on 01/23/2014. Continued review revealed no documentation of a letter of resolution.
On 04/24/2014 at 0816 interview with the Director of Patient Safety and Risk Management revealed "The complaint on January 28th (2014) should have been treated as a grievance and it was not. There is no investigation or follow-up to this complaint. There was no resolution letter mailed." Interview confirmed the hospital staff failed to provide a written letter of resolution for a grievance.

Based on hospital policy and procedure review, medical record review and staff interviews, the hospital nursing staff failed to administer blood according to facility policy for 1 of 3 blood transfusions (Patient # 2).

The findings include:

Review of hospital policy titled "Blood Administration" revised January 2014 revealed Platelets Hang Time as "20-60 minutes depending on total volume up to 4 hours."

Open medical record review of Patient #2 revealed an 88 year old admitted 04/14/2014 at 0614 with right upper quadrant pain, determined to be cholecystitis (gallbladder inflammation), cholecystectomy (gallbladder removal) planned. Review revealed the patient was transported to the operating room, but found to have low platelets and returned to Unit A prior to surgery. Review revealed physician order on 04/14/2014 at 1010 to "transfuse 6 pk (pack) Plts (Platelets) STAT (as soon as possible) before surgery....After transfusion draw a STAT Platelet count and notify (physician name) of results." Further review revealed the transfusion was started at 1310 and completed at 1322 (12 minutes later). Review revealed 200 mls (milliliters) volume given. Record review revealed no physician order for rapid infusion or timed infusion of Platelets. Further review revealed at 1356 (34 minutes later) the patient developed shortness of breath and "acute respiratory failure felt likely secondary to acute congestive heart failure. ..." Continued review revealed a decision to delay surgery and instead place a cholecystostomy (gallbladder) drainage tube. Review revealed the gallbladder drainage tube was inserted 04/15/2014 (the next day).

Interview with the RN (Registered Nurse) who administered the blood on 04/23/2014 at 1245 revealed she interpreted STAT to mean start the blood right away. Interview confirmed the policy stated a transfusion time of 20-60 minutes. Interview confirmed the platelets were infused in 12 minutes.

Interview with NM (Nurse Manager) #1 on 04/24/2014 at 0910 confirmed the platelets were infused too quickly.

NC00091923