HospitalInspections.org

Based on interview and record review the facility failed to ensure that grievances submitted in writing were addressed, investigated and followed up accurately and timely per facility policy for one (#4) of one patients reviewed from grievances log, resulting in a missed opportunity for quality improvement and decreased patient satisfaction for the patient of concern. Findings include:

On 5/8 at 1545, an interview with Patient Experience Director Staff O (also present Director of Quality Staff B) in the conference room, revealed that he was aware of complaints regarding the care of Pt. #4 and 2/13/2023 and stated they were reported up through unit, Cardiac 9, Surgical Intensive Care (SICU) manager (who is on leave and unavailable for interview). Staff O stated that he was notified that the concerns were managed verbally and considered them as "complaints" not "grievances" and that they were resolved at the unit level. Staff O also stated he was aware of an email dated 2/17/2023 from the complainant. No actions were taken in response to the email.

An email from the complainant dated 2/17/2023, was reviewed on 5/8/2023, allegations submitted to the State Intake on this survey were included in the email including pressure ulcer development, diet concerns, staff rudeness, and visitation; with a request to investigate concerns.

An interview with RN Staff AA, assigned to care for Pt. #4 on 2/10/2023 -2/12/2023 was unable to be conducted as she was placed on administrative leave on 5/3/2023. The personal file of RN Staff AA revealed no documentation of the administrative leave initiating on 5/3/2023. On 5/9/2023 at 1500 Quality Director Staff B stated she would find out reason for administrative leave and returned to the conference room at 1500 with a verbal report that Staff AA was on leave for nursing practice issues, regarding medications and critical vital signs in which caused no harm to patient.

On 5/9/2023 a document review occurred of the facility policy titled, "Patient and Family Complaints and Grievances," dated September 11, 2020, stated, "A formal written complaint that is made to the hospital by a patient or the patient's representative (these include any request that their complaint be handled as a formal grievance with a response)."

Based on observation, interview, and document review, the facility failed to ensure a clean and sanitary environment resulting in the potential to spread infectious agents to all patients in the Emergency Department (ED) and on unit 9 ICU (Intensive Care Unit). Findings include:

On 5/8/2023 at 1045 during a tour of the 9 ICU observation revealed two chest tube collection devices underneath the handwashing sink. The collection devices were disconnected from the patient, contained body fluids, and were not stored in a biohazard waste bag or bin.

On 5/8/2023 at 1100 an interview occurred with staff U, the unit manager. Staff U was queried if full chest tube collection devices should be stored underneath the handwashing sink. Staff U responded, "No...those should be moved to a soiled utility room and bagged in a biohazard waste bag."

On 5/8/2023 at 1355 during a tour of the Emergency Department observation revealed a large biohazard waste container sitting on the hallway floor. The biohazard container was unsecured and it was filled 1 inch from the top with syringes and blood filled tubing.

On 5/8/2023 at 1400, staff W, the ED nurse manager was queried about the full biohazard collection device being located on the hallway floor and who was responsible for removing biohazard collection devices. Staff W responded, "The hospital has a contracted company that is responsible for going through the facility and removing the biohazard collection devices." Staff W was then asked if the container was supposed to remain on the floor with the container being full one inch from the top. Staff W agreed that the container was over the fill mark and again stated that the contracted company was responsible for securing and removing the biohazard collection device.

On 5/9/2023 at 1230 a document review occurred of the policy titled, "Medical Waste Plan (Regulated)," Policy No: 1 EC 033 and 2 IC 021 dated 05/09/2023 (sic) states on page 2 under the subtitle "3. Methods of Decontamination or Disposal,...D. Sharps shall be disposed of in all locations by placement in rigid puncture proof containers that are appropriately labeled with the biohazard symbol. Sharps include needles, syringes, scalpels, glass tubes, urine cup blue transfer lids, pipettes, etc. that could puncture plastic bags. Filled, locked containers are exchanged at point of service by the vendor. If containers are filled before the vendor replaces them, they are locked and placed in the soiled utility rooms (meeting HVAC requirements for pressurization supply and exchange). The contracted vendor is responsible for transporting them to a separate storage area." Further review of the policy stated, "F. Liquid body fluids that cannot be flushed into the sewer system are bagged, placed into biohazard labeled impervious bins and sealed to prevent leakage. The sealed containers are transported to the designated area by Environmental Services staff."