HospitalInspections.org

.
Based on interview, review of three patient grievances, review of hospital policies and procedures, the hospital failed to ensure that patients were provided with a written response to their grievances for 3 of 3 grievances reviewed (Patients #1, #2, #3)

Failure to provide patients with a written response to their grievance violates their right to be informed of how the hospital investigated and resolved the grievance.

Findings:

1. On 10/7/2016 at 10:20 AM, Surveyor #4 reviewed three patients grievances submitted by Patient's #1, #2, and #3. These grievances alleged that the patients had been abused by staff during their hospital stay. The grievance information provided did not include the evidence that the patients had been informed of the results of the hospital's investigation of their complaints.

2. On 10/7/2016 at 11:00 AM during an interview with Surveyor #4, the hospital's Chief Operating Officer (Staff Member #1) confirmed that the patients had not been provided with a written response informing them of how the hospital had investigated and resolved their grievances.

3. Review of the hospital's policies and procedures entitled "Patient Complaints" (Policy No. 1.38; Reviewed 7/2016) and "Patient Abuse: Procedure Reporting" (Policy No. 1.29; Reviewed 9/2015) revealed that the policies did not identify how patients were to be informed of the steps taken during the complaint investigation process and results of the investigation.
.

.
Based on personnel record review and review of hospital policy and procedure, the hospital failed to ensure that staff members were current in cardiopulmonary resuscitation certification (CPR) for 2 out of 10 files reviewed (Staff Members #4, #5).
.
Failure to maintain current CPR training risks inability of hospital personnel to respond correctly to a cardiac or respiratory emergency.
.
Findings:
.

1. The Eastern State Hospital Manual policy titled, "Cardio-Pulmonary Resuscitation (CPR)" (Last Reviewed 4/15) read in part: "CPR is an emergency life-saving measure. Medical, Rehabilitation Services, Security staff and Nursing staff are required [sic] maintain certification in Basic Life Support instructor/provider unless completing Advanced Cardiac Life Support training through the American Heart Association. There is a two year cycle to ensure all clinical staff is in compliance with the new two year certification."
.

2. On 10/06/2016 at 1:30 PM, Surveyor #1 reviewed personnel files with the Human Resources Manager (Staff Member #3). Review of the personnel file of a registered nurse (Staff Member #4) and a mental health technician (Staff Member #5) revealed that both staff members received cardiopulmonary resuscitation training on 5/13/2014 and 9/22/2014 respectively and had not received an updated training within the two year cycle as required by policy.
.