HospitalInspections.org

Based on record review and interview the hospital failed to ensure the provision of a response to a grievance, in that 8 of 8 (Patients #9, #10, #11, #12, #13, #14, #15, and #16) patients did not received a response to grievance within specific time frames.

Findings Included:

Patient #9 filed a grievance on 2/19/16 and the initial response letter was sent on 3/3/16.

Patient #10 filed a grievance on 3/4/16 and the initial response letter was sent on 3/25/16.

Patient #11 filed a grievance on 3/16/16 and the initial response letter was sent on 4/14/16.

Patient #12 filed a grievance on 3/16/16 and the initial response letter was sent on 3/25/16.

Patient #13 filed a grievance on 4/4/16 and the initial response letter was sent on 4/14/16.

Patient #14 filed a grievance on 8/11/16 and the initial response letter was sent on 9/9/16.

Patient #15 filed a grievance on 10/5/16 and the initial response letter was sent on 10/24/16.

Patient #16 filed a grievance on 11/2/16 and the initial response letter was sent on 11/11/16.

During an interview on 2/13/17 at 1:10 PM in the Administration Office Personnel #1 and Personnel #2 verified the dates the grievances were filed and the response letters were sent.

The policy titled Grievance/Complaint Process dated 3/2016 reflected...If we are unable to resolve the issue on the spot, within 7 days following the submission, the patient will be provided with a written notice...

Based on record review and interview the hospital failed to ensure the blood transfusions were administered in accordance with state law and approved policy and procedures, in that 2 of 3 (Patient #1 and #4) patients did not have their blood products checked by 2 nurses prior to blood administration.

Findings Included

Patient #1 was administered 2 units of blood on 4/7/16. The first unit was issued at 12:56 AM and the second unit was issued at 4:34 AM, neither Transfusion tag evidenced 2 nurses signatures showing that the blood product was checked prior to infusion.

Patient #4 was administered 2 units of blood on 4/29/16. The first unit was issued at 10:43 AM and the second unit was issued at 11:46 AM, neither Transfusion tag evidenced two nurses signatures showing that the blood product was check prior to infusion.

During an interview on 2/13/27 at 2:00 PM Personnel #1 verified there was only 1 nurses signature on the Transfusion tag.

The policy titled Blood Components: Ordering, Obtaining and Administration dated 2/97 and reviewed 2/16 reflected...At the bedside, two nurses...check...both nurses sign the transfusion slip...