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Based on review of records and interview, the hospital did not follow their grievance process, in that, they did not send a written response to the complainant for Patient #1 within their designated policy time frame.

Review of the hospital's "Patient/Family Complaint Forms," used to log all complaints and grievances, noted that Patient # 1's daughter (complainant) had filed a complaint by telephone on 01/09/09, while the patient was hospitalized (discharged 01/13/09). The complainant stated two issues:
1) The first issue was a complaint that was resolved that day, 01/09/09.

2) The second issue alleged by the complainant was "that a nurse on the 4th floor (Personnel # 14), helped turn her mother and that later her mother had to go back to surgery with a liver tear."
Investigative Findings noted that the director had explained in a follow-up telephone call on 01/09/09 to the complainant "that a lacerated liver would not occur due to turning a patient."

Action Taken/Resolution noted that a letter was sent on 01/27/09 by the director, and the "Complainant Notified of Resolution," was checked "Yes."

The letter sent to the complainant was dated 01/27/09, which was 18 days after the complaint was received on 01/09/09. Subtracting the 6 week-end days from that 18 day period, leaves a time frame of 12 days before a written response was provided.

The hospital's "Patient Complaints/Grievance Process," policy last revised 02/07, noted that the:
-Purpose, of this policy, one of which was "to establish a written notice of the resolution of a formal grievance for the patient or the patient's representative that contains required information..."
-Definition of a grievance is "a formal, written or verbal grievance that is filed by the patient or patient's representative...when the issue cannot be resolved promptly by the staff present."
"Patient grievance also includes situations where patient or the patient's representative call or write to the hospital about concerns related to care..., who were not able to resolve their concerns during their stay..."
-Procedure notes that "if the complaint is not resolved within a reasonable time by the staff present, a written response will be provided within seven (7) business days."

In an interview with the surveyor the afternoon of 04/26/10 in the conference room, the Director of the Cardiac Care Unit (CCU), (Personnel # 4), was asked: "Was the response within the policy time frame?" She replied the hospital had not followed this allegation as a "grievance," and had not sent a written response to the complainant within the 7 business days specified by their hospital policy.

Based on review of records and interviews, the hospital did not provide a written notice with the required components, to the patient's (Patient #1) representative, for 1 of 1 complaints filed in January 2009 regarding allegations of patient injury caused by hospital staff.

Review of the hospital's "Patient/Family Complaint Forms," used to log all complaints and grievances, noted that Patient # 1's daughter (complainant) had filed a complaint by telephone on 01/09/09, while the patient was still hospitalized. The complainant stated two issues:
1) A nurse on the 4th floor (Personnel # 14) "helped turn her mother and that later her mother had to go back to surgery with a liver tear."
2) Patient #1 was "about to be transferred back to a regular floor," and the complainant "did not want her mother to have this nurse again."

Investigative Findings noted the Director of the Cardiac Care Unit (CCU), (Personnel # 4) had called the complainant on 01/09/09, had assured the complainant that her mother would be transferred to the 5th floor later that day, and would therefore, not receive care from the nurse (Personnel # 14) who worked on the 4th floor. This record also documented that the director had explained "that a lacerated liver would not occur due to turning a patient." It was noted that the complainant "was satisfied with this."

Action Taken/Resolution noted that a letter was sent on 01/27/09 by the director, and the "Complainant Notified of Resolution," was checked "Yes."

The letter sent on 01/27/09 did not contain a written notice of the hospital's decision regarding the alleged liver laceration caused by a nurse turning the patient, the specific steps taken on behalf of the patient to investigate the grievance, or the date of completion of the investigation.

The hospital's "Patient Complaints/Grievance Process," policy last revised 02/07, noted that the:
-Purpose, of this policy, one of which was "to establish a written notice of the resolution of a formal grievance for the patient or the patient's representative that contains required information..."
-Definition of a grievance is "a formal, written or verbal grievance that is filed by the patient or patient's representative...when the issue cannot be resolved promptly by the staff present."
"Patient grievance also includes situations where patient or the patient's representative call or write to the hospital about concerns related to care..., who were not able to resolve their concerns during their stay..."

In an interview with the Director of the Cardiac Care Unit (CCU), (Personnel # 4) the afternoon of 04/26/10, she was asked whether the response to this complaint contained the required components. She replied that the letter sent to the complainant did not follow their hospital policy as it did not contain the required regulatory components.

Based on review of records and interview, the hospital did not identify an adverse patient event for 1 of 1 surgical patients (Patient #1), through it's hospital-wide Quality Assurance Performance Improvement (QAPI) program, and had not assessed the quality of care this patient received during her hospitalization from 12/16/08 to 01/13/09.

The medical record for Patient #1 showed the following sequence of events with 3 "Returns to the Operating Room (OR)" during her inpatient stay:
1) The patient was admitted on 12/16/08 for a planned repair of a paraesophageal hernia with Stamm gastrostomy (G-tube).
2) The surgical resident's (Personnel #9) progress notes for this patient on 12/24/08 at 0850, noted "G-tube cut by nursing last PM- balloon obviously deflated- G-tube unsecured..." This note also described the resident's unsuccessful efforts to replace the G-tube.
3) Nursing notes for the night shift of 12/23/08 did not include documentation of a cut G-tube, and only noted the G-tube to gravity.
4) The patient's 1st return to the OR was on 12/30/08, with noted indication for this surgery to be that "her G-tube was accidentally severed resulting in gastrocutaneous fistula that failed to resolve on its own"...requiring "closure of the gastric venous fistula ..."
5) On 01/03/09 the patient had shortness of breath (SOB), was lethargic and had abdominal pain, and was transferred to the critical care unit (CCU). A computerized axial tomography (CAT) scan showed air in the peritoneum and contrast within the peritoneal cavity "indicating perforation of the gastrointestinal (GI) tract, probably stomach..." The patient's 2nd return to the OR was on 01/03/09 for peritonitis and gastric perforation.
6) On 01/04/09 the patient's 3rd return to the OR was for Post-operative bleeding, hematoma evacuation, and revision of the gastric perforation omental patch. It is was noted that a falciform ligament tear and a left lobe of liver tear were discovered during this operation.

The hospital "Occurrence Reporting - Meditech" policy, with a revised date of 03/04 at the time of this occurrence, noted that:
-"Situations with either the potential for or which actually result in injury to an individual...will be reported using the Meditech system occurrence report."
-"Risk Management is responsible for data collection, statistical analysis and reporting requirements of patient...notifications, in keeping with the hospital-wide risk management program..."

In a telephone interview with the attending general surgeon (Personnel # 8) the afternoon of 04/28/10, he confirmed that the 3 returns to surgery past the original operation were "unplanned, and started when the G-tube was accidentally cut, resulting in a gastrocutaneous fistula. "

In an interview with the Vice President of Quality Management (Personnel #3) the afternoon of 04/28/10, she was asked if the above adverse patient event regarding Patient #1's G-tube had been captured in the hospital's QAPI program. She said "no." She verified that no occurrence report had been completed by nursing staff, and that the hospital's surgery service indicators had not tracked "return to surgery" events at that time.