HospitalInspections.org

Based on record review and interview, the facility failed to promote patient rights as evidence by failure to follow procedures for prompt resolution of patient complaints for 1 of 6 sampled patients (SP#2) who personally filed a complaint regarding an erroneous laboratory result but failed to receive an appropriate response, action or explanation on a timely manner.

Findings Include:

Interview with the Licensure and Certification Coordinator (LCC) on 9/27/10 at around 1045 AM revealed
that the facility was already investigated by the Agency (AHCA) on 9/16/10 regarding a complaint
involving erroneous test results reported by the laboratory department. The LCC also stated that the
TJC (The Joint Commission) also sent the facility a patient complaint involving the same incident and
requested an investigation and response to the allegations. The LCC further stated that the department
heads involved with the incident have met and a RCA (Root Cause Analysis) was done , corrective
action plans were developed and will be submitted to the Agency. The facility is also currently preparing
an official response to the TJC inquiry about the complaint.

Clinical record review conducted on 9/27 and 9/28/10 revealed that SP#2 was seen at the facility's outpatient services and lab works were done including a test for HIV (Human Immunodeficiency Virus) on 06/03/10.

Review of the Facilty's clinical lab survey with the event ID 2M0E11 conducted on 9/16/10 by the Agency (AHCA) confirmed that an erroneous HIV Lab result was provided to SP#2.
Interview with the Asst. Administrator of Patient Relations (AAPR)conducted on 9/27/10 at 1240 PM
confirmed the allegation that SP#2 personally came Patient Relations office on 06/17/10 and filed a
complaint about the erroneous lab results and requested for an investigation and a follow up. The
Patient Relations Asst. Administrator stated that the patient relations staff took the information and
immediately sent the complaint to the Laboratory Director via the Quantros Feedback Manager
(Complaint/Compliment Tracking System). The AAPR further stated that the PR Representative are to
include action taken for complaint resolution and also responsible for follow up on their reports to
ensure that the complaint has been resolved. The expected resolution or response time is within 7 days if
not resolved immediately. A follow up Ticket is activated if the response due date is approaching and
the attention of the responsible department head is called. The AAPR stated that the Quantros Feedback
Manager record showed that that the complaint was closed. The AAPR was unable to explain why the
PR Representative closed the case without resolution. There was no evidence to show that the PR Staff
personally called the lab for a quick resolution of the complaint nor evidence to show that a follow call to
the complainant was made. AAPR further stated that the department has already started on reinforcing
the complaints/grievance policies and procedures though reeducation and in services. Hospital wide
awareness is in the process starting with the PR representatives. Policies and Procedures are being
reviewed and make the necessary changes to ensure that complaints are properly addressed and
resolution is achieved.

Interview with the Lab Director and the Asst. Clinical Manager conducted on 9/28/10 at 1130 AM
revealed that they were not aware of the complaint until an investigation was already conducted. Both
Lab Managers stated that if someone from the Patient Relations send a message to the Quantros
Feedback Manager they would know about the complaint unless they are prompted to check the
message. The system at this time does not prompt that an urgent message is present that needed
attention. The Lab Director further stated that if the PR representative called the Lab when the patient
was there complaining, they would have send someone to resolve the issue immediately.