HospitalInspections.org

Based on document review and interview, the hospital failed to follow its policy for patient grievances.

Findings:

1. Review of a hospital policy entitled Patient/Family Complaints/Grievances, revised
06-09-10 by authorized hospital personnel, indicated once a staff member becomes aware of a patient, family or patient representative complaint or grievance, the staff member is responsible for completing or assisting with the completion of a "Patient/Family Complaint" form and then forwarding the form to the Risk Manager. The Risk Manager will then review the complaint and forward to the appropriate manager for follow-up.

2. Review of patient medical record #MR#4, indicated on 1-21-13 at 1545-1605 hours, there was an entry on the Multidisciplinary Progress Notes by employee #A4 indicating Patient stated, "I will be calling the Board of Health [Facility #1] as soon as possible as it was in-humane the way it got cold in here." Patient went on to state that she knows "several patients" that are also calling the [Facility #1] due to heat issues.

3. Hospital staff were requested to provide a copy of a Patient/Family Complaint form relative to this complaint/grievance. In interview on 02-25-13 at 2:15 pm, employee #A1 and employee #A3 indicated there was no completed form available and no other documentation was provided prior to exit. Thus, the hospital failed to follow their policy.

Based on document review, interview and observation, the facility failed to adequately secure various materials and supplies to effectuate repairs to maintain the facility.

Findings:

1. Review of a document entitled Plan of Correction, indicated the results of a survey conducted 1/3/2013, by Facility #2, indicated a statement of non-compliance with a rule, the finding being, very difficult to get adequate warm water for handwashing temp not above 60 [degrees] fahrenheit after 20 sec. It also indicated the hospital would investigate and take appropriate action to increase water temperature of water faucets.

2. In interview, on 2-25-13 at 11:00 am, employee #A1 indicated the facility had been aware since 1-17-13 of a problem with the water temperature coming from patient water faucets, due to the results of the above-stated survey. The employee indicated the facility had started to take action to correct it and anticipated the problem would be corrected by 3-15-13.

3. In interview, on 2-25-13 at 11:15 am, employee #A2 indicated he had become aware of the water temperature problem at the same time as employee #A1. The employee indicated the problem, poor functioning mixing valves, had been addressed and the work would be started as soon as the owner approved of an expenditure of funds to correct the problem.

4. In interview, on 2-25-13 at 11:40 am employee # A3 indicated the Environmental Care/Safety Committee had discussed the issue of the inpatient handwashing sinks and the forthcoming change of the water delivery system in order to overcome the current problem of inadequate water temperature.

5. Review of a document entitled CARPACRequest, dated 02/19/2013, indicated employee #A2 had requested approval by the owner for an expenditure of $9,715.00 to purchase and have installed mixing valves for faucets, based on a bid from an outside vendor to perform the work. As of the date of the survey, this expenditure has not been approved and no repair work has been started on the mixing valves of the patient hand wash sinks.

6. On 2-25-13, at 3:00 pm, in the presence of employee #A2, Adult Psych Patient Rooms 214 through 228, and adjoining areas, were observed. The surveyor turned on a hot water valve on a sink faucet in one of the patient rooms. The water temperature felt cool to the touch and not as warm as would be normally expected.

Based on document review and interview, the hospital Infection Control Officer failed to assure written housekeeping processes were identified as policies and were signed by authorized hospital personnel.

Findings:

1. Review of various housekeeping policies and procedures that addressed techniques for cleaning and disinfecting environmental surfaces, carpeting and furniture, indicated they were not approved by authorized hospital personnel.

2. In interview, on 02-25-13 at 1:45 pm, employee #A4 confirmed the above policies and procedures were not approved by authorized hospital personnel and no further documentation was provided prior to exit.