HospitalInspections.org

Based on document review and interview it was determined for 1 of 3 (Pt. #1) grievance files reviewed, the hospital failed to investigate all portions of the grievance.

Findings include:

1. Hospital policy titled, "Complaint and Grievance Policy (revised 7/09)" stated in part, "The Department of Customer Relations will address all concerns in a timely, reasonable manner..."

2. The patient complaint log for 2013 was reviewed on 9/18/13. Pt. #1 was identified in the log. The clinical record, as well as, complaint file was requested. The telephone grievance received 7/1/13 included a concern about a tourniquet being left on Pt. #1's arm for over four hours. The tourniquet was never addressed in the written hospital response dated 7/3/13 to the complainant.

3. The Patient Advocate (E#1) was interviewed on 9/18/13 at 2:45 PM. E#1 stated, " ... I completed the complaint investigation on this patient (Pt. #1). I missed investigating the portion about the tourniquet being left on from the complaint. It was an oversight."

Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed for patient incidents, the hospital failed to ensure an incident report was completed for an unexpected patient event.

Findings include:

1. Hospital policy titled, "Quality Improvement Reporting For Patients, Visitors, and Others (revised 2/13)" stated in part, "... report and investigate any event not consistent with routine patient care delivery or routine operations (of the hospital) in order to reduce and/or prevent the risk of future recurrence ... for improving patient care."

2. The clinical record of Pt. #1 was reviewed on 9/18/13. Pt. #1 was an 82 year old male admitted on 5/31/13 with the diagnoses of hallucinations and hypothyroidism. The clinical record included a physician's order dated 6/1/13 at 1:59 PM for several blood tests to be drawn in the AM of 6/2/13. A complete blood count, a comprehensive metabolic panel and a prothrombin time were drawn at 4:03 AM on 6/2/13.

The nurses' note dated 6/2/13 at 9:20 AM stated in part, " Patient found to have a tourniquet on right upper arm. Tourniquet removed and red indentation left around right upper arm in its place. No edema to arm. Pulse present. Temperature warm and capillary refill less than 3. "

3. The Phlebotomist (E#2) who collected the blood from Pt. #2 on 6/2/13 was interviewed via telephone on 9/18/13 at 10:30 PM (called during work shift). E#2 was never made aware of an incident with Pt. #1 or any other incident where a tourniquet was left on a patients arm.

4. The LPN (licensed practical nurse) (E#3) who found the tourniquet on Pt. #1's arm was interviewed on 9/19/13 at 10:00 AM. E#3 remembers having a conversation with the other staff about how to document the incident and whether to fill out an incident report. E#3 sated, "I don't remember filling out a report or why one was not completed. One should have been."

Based on document review and interview it was determined for 1 of 3 (Pt. #1) grievance files reviewed, the hospital failed to investigate all portions of the grievance.

Findings include:

1. Hospital policy titled, "Complaint and Grievance Policy (revised 7/09)" stated in part, "The Department of Customer Relations will address all concerns in a timely, reasonable manner..."

2. The patient complaint log for 2013 was reviewed on 9/18/13. Pt. #1 was identified in the log. The clinical record, as well as, complaint file was requested. The telephone grievance received 7/1/13 included a concern about a tourniquet being left on Pt. #1's arm for over four hours. The tourniquet was never addressed in the written hospital response dated 7/3/13 to the complainant.

3. The Patient Advocate (E#1) was interviewed on 9/18/13 at 2:45 PM. E#1 stated, " ... I completed the complaint investigation on this patient (Pt. #1). I missed investigating the portion about the tourniquet being left on from the complaint. It was an oversight."

Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed for patient incidents, the hospital failed to ensure an incident report was completed for an unexpected patient event.

Findings include:

1. Hospital policy titled, "Quality Improvement Reporting For Patients, Visitors, and Others (revised 2/13)" stated in part, "... report and investigate any event not consistent with routine patient care delivery or routine operations (of the hospital) in order to reduce and/or prevent the risk of future recurrence ... for improving patient care."

2. The clinical record of Pt. #1 was reviewed on 9/18/13. Pt. #1 was an 82 year old male admitted on 5/31/13 with the diagnoses of hallucinations and hypothyroidism. The clinical record included a physician's order dated 6/1/13 at 1:59 PM for several blood tests to be drawn in the AM of 6/2/13. A complete blood count, a comprehensive metabolic panel and a prothrombin time were drawn at 4:03 AM on 6/2/13.

The nurses' note dated 6/2/13 at 9:20 AM stated in part, " Patient found to have a tourniquet on right upper arm. Tourniquet removed and red indentation left around right upper arm in its place. No edema to arm. Pulse present. Temperature warm and capillary refill less than 3. "

3. The Phlebotomist (E#2) who collected the blood from Pt. #2 on 6/2/13 was interviewed via telephone on 9/18/13 at 10:30 PM (called during work shift). E#2 was never made aware of an incident with Pt. #1 or any other incident where a tourniquet was left on a patients arm.

4. The LPN (licensed practical nurse) (E#3) who found the tourniquet on Pt. #1's arm was interviewed on 9/19/13 at 10:00 AM. E#3 remembers having a conversation with the other staff about how to document the incident and whether to fill out an incident report. E#3 sated, "I don't remember filling out a report or why one was not completed. One should have been."