HospitalInspections.org

Based on hospital policy and procedure review, grievance file review and staff interview, the hospital staff failed to provide written notice of the resolution of a grievance in 3 of 3 grievances reviewed (#1, 2 and 5).

The findings include:

Review of the hospital's policy, "Customer Relations and Patient Concerns/Grievances Resolutions", revised 04/2011, revealed, "...Procedure: ...II. Upon referral from any staff member or at the time of the Patient Representative regularly scheduled visit to a patient, family member or visitor, the Patient Representative will receive any concerns or grievances. ...IV. A grievance is a formal written or verbal concern that cannot be resolved promptly and is major in scope. ...D. The Director of Patient Relations will provide a written response within 7 business days to the patient or his/her representative that the Hospital has started its formal Patient Care Grievance Process and that follow-up will be provided to the patient or his/her representative within a reasonable time frame. 1. If the grievance has been resolved within the 7 day time frame, the letter will include the name of the hospital contact person, steps taken to investigate the grievance, results of the grievance process, and the date of completion. E. After the investigation is complete and the Patient Care Grievance Committee has implemented any opportunities for improvement learned from the grievance, the Director of Patient Relations will follow-up in writing to the patient or his/her representative in a reasonable time frame, but no (not) greater than 90 days. ...".

1. Review of Patient #1's grievance file on 03/07/2012 revealed a grievance was submitted 09/05/2011 related to morgue access after Patient #1 drowned 09/05/2011 and was brought to the hospital's morgue. File review revealed no documentation that a letter was sent to the complainant with name of hospital contact person, steps taken to investigate the grievance, results of the grievance process and the date of completion.

Interview on 03/07/2012 at 1100 with the director of patient relations confirmed a follow-up letter was not sent to the complainant after a grievance was filed 09/05/2011 (7 months ago). Interview revealed the hospital's grievance policy was not followed.

2. Review of Patient #2's grievance file on 03/07/2012 revealed a grievance was submitted 12/21/2011 related to the care of Patient #2 in CCU (Critical Care Unit). File review revealed a letter was sent to the complainant on 12/26/2011 stating the grievance was being investigated. File review revealed no documentation that a letter was sent to the complainant with name of hospital contact person, steps taken to investigate the grievance, results of the grievance process and the date of completion.

Interview on 03/07/2012 at 1100 with the director of patient relations revealed the grievance file was closed and completed. Interview revealed, "I talked to (complainant) after she complained and thought that was enough". Interview confirmed a follow-up letter was not sent to the complainant after a grievance was filed 12/26/2011 (72 days ago) Interview revealed the hospital's grievance policy was not followed.



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3. Review of the hospital's grievance log January 1, 2012 through March 6, 2012 revealed no evidence of a grievance filed for Patient #5.

Interview on 03/08/2012 at 1135 with the Director of Safety and Security revealed he had received telephone calls from Patient #5's family complaining about the use of handcuffs and shackles in the emergency department and the denial of family visitation or phone calls during Patient #5 visit to the emergency department from 01/25/2012 through 02/10/2010. Interview revealed a decision was made to deny family visitation and phone calls collaboratively between the hospital staff, emergency department physicians and the sheriff's department. Interview revealed the patient was observed to become agitated during and after family phone calls. Interview revealed the county sheriff's department was present with the patient while he was in the emergency department and handcuffs and shackles were applied by the deputies. Interview revealed the staff member had talked with the patient's family members several times regarding these issues and had referred the patient's father to the county sheriff's office (Lieutenant X). Interview revealed the staff member had no documentation of the discussions or phone calls between himself and the family members or himself and the sheriff's department. Interview revealed the staff member was unable to remember specific dates and times of the phone calls, but knew that the complaint was voiced while the patient was in the emergency department. Interview revealed the staff member did not document this complaint as a grievance and stated "It should have been a grievance." Interview confirmed no documentation that a letter was sent to the complainant with name of hospital contact person, steps taken to investigate the grievance, results of the grievance process and the date of completion.

Interview on 03/07/2012 at 1130 with the Director of Patient Relations confirmed there was no grievance on file for Patient #5. Interview confirmed a follow-up letter was not sent to the complainant regarding this grievance. Interview revealed the hospital's grievance policy was not followed.

Based on hospital policy review and staff interview, the hospital staff failed to track adverse patient events as evidenced by failing to complete an occurrence report on an assault to a police officer by a patient in the emergency department for 1 of 1 patient assaults reviewed (Patient #5).

The findings include:

Review of the hospital's policy, "Incident Reporting" revised 03/2011, revealed, "POLICY: Events not consistent with the routine care of patients or that could result in an injury to a patient, visitor, employee or other individual will be measured and assessed to identify opportunities for improvement.
...PROCEDURE: ...I.A. All incidents (except medication incidents) involving patients, visitors or non-employee staff (physicians, students, contract persons) will be documented on the Performance Improvement Data Collection Tool. B. The Performance Improvement Data Collection Tool will be completed by the person discovering the incident and will forwarded to his/her department manager. C. The Performance Improvement Data Collection Tool will then be sent to the Risk Manager for review and any further investigation necessary. D. Aggregate data on incidents will be reported by Risk Management to the appropriate department, lead team and/or committee no less than quarterly...."

Closed record review on 03/07/2012 of Patient #5 revealed a 32 year-old male that presented to the emergency department on 01/25/2012 with bipolar and schizoaffective disorders. Review revealed the patient remained in the emergency department pending placement for inpatient psychiatric admission through 02/10/2012 when he was transferred to another facility. Review of the record revealed the patient had a history of violent behavior and county deputies (non-employed law enforcement) remained with the patient during the time the patient was in the emergency department. Review of nursing notes revealed a "late entry" note documented on 01/30/2012 at 2147 that stated the nurse was called to the patient's room at 2135 when the patient "punched the officer in the face. The officer wrestled the patient to the ground and applied handcuffs."

Interview on 03/07/2012 at 1525 with RN (Registered Nurse) #1 revealed she was the primary nurse assigned to Patient #5 on 01/30/2012 when the patient hit the police officer. Interview revealed the nurse failed to complete an occurrence report. Interview confirmed the hospital policy for documenting an occurrence report was not followed.

Interview on 03/07/2012 at 0950 with the Director of Security confirmed no documentation of an occurrence report being completed for the police officer that was hit by Patient #5 in the emergency department on 01/30/2012.

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