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Based on policy review and interview, the facility failed to respond to four of eight patient related grievances (#1, #5, #16, #17) for the timely resolution of a grievance resulting in the potential loss of rights to all patients being served by the facility. Findings include:

On 1/17/2017 at 1430 during review of patient #1 medical record, staff C stated a complaint had been filed by the patient's father. Staff C was asked to provided the information in regards to the complaint. Review of the information provided showed that a complaint was received on 12/7/2016 in which the patient's father stated that patient #1 was transferred on 12/3/2016 to facility B due to facility A not being able to be treat the patient (#1). The documentation further stated that the patient had undergone surgery at facility A on 11/15/2016 and subsequently had been diagnosed with a surgical site infection at the primary care physician's office on 12/2/2016. The patient was then seen at facility A's emergency department on 12/3/2016 and transferred. On 12/16/2016 the infection control preventionist called the complainant. No documentation was evident of a response to the complainant as of 1/17/2017.

On 1/18/2017 at approximately 1000 an interview with the patient safety manager occurred. The patient safety manager was queried as to the process of responding to a complainant of a grievance. The patient safety manager stated the process was changed in July 2016 that any complaint received in regards to medical or clinical in nature was not designated as a complaint or grievance but directed to the department manager involved in the complaint/grievance.

On 1/18/2017 at approximately 1030 a review a complaint related to patient #5 was conducted. According to the documentation a complaint was lodged by the paternal grandfather of the patient (#5). The complaint was related to the care received at the emergency department (ED) on 11/19/2016. The complaint stated the patient (#5) had been seen at the ED and had not been diagnosed or treated appropriately. The patient safety manager was asked to show documentation for complaint/grievance resolution for the grievance. The patient safety manager responded that there was no documentation as the complaint was medical in nature and had been referred to the ED department physician.

On 1/19/2017 at approximately 0930 a review occurred of the policy titled "Patient complaint process, issues, grievances and appeals policy" dated 10/27/2016. According to the policy under the section titled "procedure" it states: "All patient grievances must be responded to in writing as soon as possible....grievances, at a minimum, should be acknowledged in writing within seven (7) days...it is expected that most grievances can be resolved and the resolution communicated in writing within 30 days. In those situations where a resolution cannot be reached in that time frame, a written response will include the anticipated date of resolution."


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Additionally,

On 1/19/2017 at 0900 it was revealed that there was no documentation of follow up letters for the clinical care complaints for patient #16 or #17. This was confirmed by staff B Patient safety manager and staff C patient relations manager.

Based on interview, and document review the facility failed to establish a process for all Clinically Responsible Persons to report infections. Resulting in the lost opportunity to improve patient outcomes for all patients treated at this facility. Findings include:

On 1/17/2017 at 1600 during a meeting with staff B the patient safety manager and staff C the patient relations manager the process for adverse events reporting including infections was discussed. Staff C stated "in July of 2016 the process was changed from a grievance to a clinical risk event." When asked for a copy of this new process for how clinical staff was to report adverse events including infections staff C stated "We do not have a written document."

On 1/18/2017 at 1100 during review of the medical record for patient #1 it was found: Patient #1 was a 22 month old female, her original surgery was on 11/15/2016 for a trigger thumb on her left hand. The patient was placed in a cast and sent home. On 11/28/2016 she was seen at her primary care physician and the cast was removed, the incision was documented as no redness. Four days later on 12/2/2016 patient #1 was seen by her Primary care Physician (located within the hospital) related to redness and swelling of the incision on her left thumb. She was placed on an antibiotic and sent home. On 12/3/2016 patient #1 was seen in the Emergency Room and transferred to another facility due to infection in the incision of the left thumb.

On 1/18/2017 at 1300 during an interview with staff G the infection Preventionist, she stated "I did not do an investigation on the infection related to patient #1, I was not aware of the post operative infection diagnosis." She was also asked how she received information related to the infection data she reported to the quality committee and to the board, she stated "I rely on feedback from staff and physicians." She was not able to clarify how they would report that information to her.

On 1/17/2017 the Surgeon for patient #1 was queried about this post operative infection He stated "This is the first time I have heard of this patient having an infection!" He explained that he would only be able to find out about an infection if the hospital notified him or when he does the follow up appointment scheduled for January 19, 2017.