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Based on record review, policy review, and interview, the hospital failed to ensure patients' complaints were reviewed, investigated, and resolved as evidenced by failing to initiate the process of responding to a patient concerns, issues, or complaints for 1 of 6 sampled patients (#2). Findings:


On 5/23/12 at 11:15 a.m. in a face-to-face interview with S2 Chief Nursing Officer (CNO), she stated she was not aware of any complaints or issues in ICU. She added S13 RN Unit Manager was on vacation out of the country and was unavailable by phone. S2 produced a copy of S13 RN's Patient Daily Rounding Log for the month of April. S2 stated S13 uses this form while making patient daily rounds. S2 added S13 selects 2 patients to assess patient satisfaction and then documents the patient and/or family comments.

Record review of Patient Daily Rounding Log for the period 4/18/12-4/19/12 (pg 2 of 5) revealed patient #2's husband was present when S13 RN Unit Manager made rounds. Under Issues/Follow Up, S13 RN documented "none." Under Notes, Observations, and Patient Concerns, S 13 RN documented "Patient on vent." Record review of Patient Daily Rounding Log for the period of 4/23/12-4/25/12 (pg 5 of 5) revealed patient #2's husband was present when S 13 RN made rounds. Under Issues/Follow Up, S13 RN documented "visiting hours and delays of communications with docs (S10 MD)". Under Notes, Observations, and Patient Comments, S13 RN documented "Patient on vent. Comments made on night nurses." Record review of Patient Daily Rounding Log for the date 4/26/12 (pg 4 of 5) revealed patient #2's husband and children were present. Under Issues/Follow Up, S13 RN documented "ICU Psychosis." Under Notes, Observations, and Patient Comments, S13 RN documented "Patient feels staff are trying to 'kill her' and take her money. Patient loves her children."

On 5/23/12 at 11:20 a.m. in a second interview with S2 CNO, she stated her expectation for the Unit Managers is to make rounds on at least 2 patients. If the Unit Managers feel the patients' issues/concerns are complaints, then they are to initiate the "Complaint Form" per hospital policy. S2 CNO confirmed that S13 RN Unit Manager had not initiated the Complaint Form per hospital policy for 2 of 3 issues/concerns voiced by patient #2's husband and/or family members; therefore, no actions were taken for 2 of the 3 complaints.

On 5/23/12 at 11:50 a.m. in a third interview with S2 CNO, she stated she expected S13 RN ICU Unit Manager to fill out the complaint form for 2 of the 3 complaints/concerns/issues voiced by patient #2's family. S2 added, the complaint form should have been forwarded to her within 7 days.

Record review of policy titled "Complaints/Concerns/Issues" Reviewed date 11/6/01, Revised date 12/01/01, and Reviewed Date 11/04, 2/08, (pg 1 of 5) revealed under Complaint Management: Procedure notes "When a patient/family complains to a direct caregiver regarding care, the immediate supervisor in charge of the department/patient care unit should be notified without delay and every effort made, at that time, to promptly resolve the issue to the patients satisfaction. When the complaint cannot be immediately resolved to the patient's satisfaction, the hospital approved "Complaint Form" should be initiated."

The hospital failed to follow the policy for Complaint Management for 2 of 3 issues/concerns voiced by patient #2's husband and/or family members; therefore, no actions were taken to resolve these issues.

Based on interview and policy review, the hospital failed to have a system in place to consistently provide patients with a written notice of complaint outcomes as evidenced by the hospital's policy missing steps to ensure patients are provided a written decision regarding the outcomes of complaints/concerns/issues investigations. Findings:


Record review of hospital's policy titled "Complaints/Concerns/Issues" reviewed date 11/06/01, revised date 12/01/10, reviewed dated 11/04, 2/08 (pg 2 of 5) revealed the steps "the department manager initiates to follow up the day the complaint is receive by:
1. Reviewing the patient's record to determine caregivers, employees involved;
2. Discussing complaint with those involved to determine if appropriate care standards were followed;
3. Contacting patient/family to acknowledge that complaint has been received with concern, even if the investigations are not complete, and agrees to make a follow up contact later;
4. Completing follow up report documentation on reverse side of form;
5. Send completed form to Performance Improvement.

Complaints of patient care made by physicians will be investigated using the same documentation process."

On 5/23/12 at 11:50 a.m. in a face-to-face interview with S2 Chief Nursing Officer (CNO), she confirmed the hospital's policy did not include the step of providing patient and/or family members a written decision of the outcome/resolution for a complaint.

Based on interview and policy review, the hospital failed to have a system in place to analyze and track quality indicators as evidenced by not incorporating patient complaints into the QAPI process. Findings:

Record review of the policy titled "Complaints/Concerns/Issues" (pg 2 of 5) under Performance Improvement revealed that complaints are reviewed on an on-going basis; complaints are routed to administrative staff as appropriate for immediate intervention if lack of follow up by department manager is noted; and complaints are reviewed at appropriate meetings to identify trends or patterns. Under Performance Improvement Issues Report, the policy reveals (1) A Performance Improvement Issues Report is a mechanism to identify and report problems, concerns, or suggestions; (3) All completed reports should be forwarded to the Performance Improvement Department for investigation of the feasibility of the suggestion and/or the resolution of the concern."

On 5/23/12 at 10:45 a.m. in a face-to-face interview with S8 QAPI Director, she stated that the monthly grievances were turned into S14 Administrative Assistant, who compiles the information to be reviewed by the Performance Improvement Quality Council (PIQC) committee. S8 QAPI confirmed the quarterly meetings are used to discuss health information management, infection control data, hospital reports, such as medication errors, resuscitation events, and deaths, and core measures, such as the benchmarks provided by The Joint Commission. S8 confirmed the PIQC minutes since the beginning of 2012 did not contain the monthly information related to grievances/complaints.

On 5/23/12 at 11:50 a.m. in a face-to-face interview with S2 CNO, she confirmed the complaints/grievances were not analyzed and tracked as part of the QAIP process.