HospitalInspections.org

Based on review of facility documents, facility policy review, and interview, the facility failed to ensure a grievance was addressed in writing for one patient (#1) of ten patients reviewed.

The findings included:

Patient #1 was admitted to the facility on June 18, 2010, with Right Leg greater than Left Acute and Chronic Lower Extremity Cellulitis, Chronic Venous Stasis, History of Methacillin-resistant Staphylococcus Aureus and Pseudomonas, Diabetes mellitus type 2, Mild Hyperkalemia in setting of long-term ACE inhibitor therapy, and Morbid Obesity; and patient #1 was again admitted to the facility's medical floor and transferred to the ICU on October 30, 2010, with diagnoses to include Pneumonia, Dyspnea secondary to Pneumonia, Chronic Kidney Disease Stage 2, Diabetes Mellitus, and Chronic Venous Stasis with Chronic Wounds.

The facility documents relating to grievances on the first and second admissions of patient #1, dated October 26, 2010, at 10:40 a.m., revealed the family called to report the ED nurse not providing privacy by leaving the door open and no curtain pulled, did not provide a call light, and was rude when the patient was transferred to the med/surg unit. Also complained the fourth floor staff did not monitor the patient's blood sugar and tried to give the patient insulin on October 20 when the patient's blood sugar was 63. Continued instances noted by the family were on October 19, 2010, the patient did not receive breakfast until 11:00 a.m., and the staff did not dress out and may only put on gloves with a caddy on the door for MRSA (Methacillin Resistant Staphylococcus Aureus). The facility interviewed the ED nurse who denied the accusation. The issue of the blood sugar was reviewed and the physician was aware and had ordered the insulin due to the patient being on prednisone drip and antibiotics. The family wanted the accuchecks done more frequently than the four times daily but the physician had no desire to change the order. Risk Management spoke with the family on March 29, 2011.

Continued review revealed the family of patient # 1 had made a written grievance on April , 2011, at 9:00 a.m., related to the care of patient #1. Continued review revealed the facility spoke with the family about the complaints and forwarded the issue of un-resolved complaints to the Chief Executive Officer (CEO) on April 7, 2011.

Review of the facility policy Patient Grievance, # C-2, dated November 22, 2005, revealed "...The CEO is responsible for completing and sending a letter to the complainant in response to a complaint/grievance...The response letter shall be forwarded to the patient or the patient's representative no later than 7 days after the receipt of the grievance even though the hospital's resolution need not be complete within the seven-day time limit..."

Interview in the conference room with the Chief Nursing Officer and Risk Manager on November 16, 2011, at 2:45 p.m., confirmed the patient's complaints had not been addressed in writing and in a timely manner as per the facility's policy.

C/O #27884