HospitalInspections.org

Based on interview and record review the hospital failed to provide 1 of 1 patient's (Patient #1) with written notice of a grievance resolution and it's decision, that contains to name of the hospital contact person, the steps taken on behalf of the the patient to investigate the grievance, the results of the grievance process and the date of completion. Findings include:

Patient #1 was admitted to the hospital on 9/27/2011 with diagnoses that included mental retardation, urinary tract infection and confusion.

The document titled Patient Comment Referral Form dated 9/30/2011 was reviewed and revealed that the hospital received a call from Patient #1's outside caregiver, Individual C. The referral form indicated that Individual C relayed several complaints about the care Patient #1 was receiving from the hospital, including not having a Continuous Positive Airway Pressure/(CPAP) machine available for Patient #1's use. The referral form indicated that the concern was discussed with Employee D/Charge Nurse who would follow up with staff and the patient, etc.

Employee B/Patient Representative was interviewed on 12/14/2011 at 10:30 a.m. Employee B was the employee who recieved the complaint on 9/30/2011. Employee B stated that although Individual C had complaints about Patient #1's care she did not follow this up as a grievance because the patient was still hospitalized and Individual C seemed satisfied with her plan to follow up.

Employee D was interviewed on 12/9/2011 at 2:30 p.m. and stated that she did some investigation into the concerns that Individual C relayed. Employee D stated she did not know if a CPAP had been ordered for Patient #1. Employee D stated she had been covering the unit for another charge nurse and passed the concern form onto Employee E/Charge Nurse.

Employee E was interviewed on 12/13/2011 at 10:45 a.m. and she stated that she did not recall getting the concern form passed on to her, nor did she do any follow up on the concerns raised in the form.

A review of Patient #1's medical record revealed that Patient #1 had an order dated 9/29/2011 for a CPAP machine, but the facility did not have one available, so the CPAP was not initiated. Patient #1's oxygen status was monitored.

Individual C was interviewed on 12/20/2011 at 9:20 a.m. and stated that the hospital did not inform her of the resolution of her concerns.

The policy titled Patient Grievance Policy dated Jun 1, 2007 was reviewed and revealed and under section:

"H. When a patient contacts staff not immediately present on the unit or department. If a patient notifies hospital staff not immediately present on the patient's unit or department (e.g. a Patient Representative) of a complaint before the patient has notified staff on the unit or department, and the staff person reports the complaint to staff on the unit or department where the patient is and the complaint is resolved on the spot without further assistance, the complaint is not a grievance and no written response to the patient is necessary.

I. When a complaint becomes a grievance. If a complaint is not resolved on the spot as described in the two preceding paragraphs, the complaint becomes a grievance and the response must be in writing as specified in this policy."