The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GLENWOOD REGIONAL MEDICAL CENTER 503 MCMILLAN ROAD WEST MONROE, LA 71291 Dec. 7, 2011
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based upon review of the Grievance Policies and Procedures, Grievance Log, complaint investigations, and staff interviews, the governing body failed to ensure the grievance policy was followed related to: 1) The establishment of the Grievance Committee to review and resolve grievances, and 2) The data collected regarding patient grievances were incorporated into the hospital's performance improvement program. Findings:

Review of the policy titled "Patient Complaint and Grievance" Policy Number Adm.005, revealed "Grievance Committee - An ad hoc committee consisting of members defined by Administration as appropriate to the grievance type. The committee must consist of more than one person and may include members of Administration, Case Management, physician Representative, Patient Advocate, Risk Management and appropriate department managers. The committee is responsible for reviewing and resolving grievances that may require additional input, or that cannot be resolved by the Patient Advocate alone."

Interview with Risk Manager S10 on 12/07/11 at 8:50 AM, revealed she received all patient complaints, conducted the investigations, and responded back to the patient with the results. When asked if there was input from the Grievance Committee, S10 responded the last committee meeting was "a few years ago".

Further review of the Grievance Policy and Procedure revealed "6. Complaint Log and Performance Improvement. b. Data will be collected regarding patient grievances, as well as complaints that are not defined as grievances and incorporated into the organization's performance improvement program."

Review of the Quality Assurance/Performance Improvement data revealed there failed to be documented evidence the grievance process was reviewed and analyzed through the hospital's QA/PI program. Interview with the Quality Assurance Director S9 on 10/06/11 at 10:50 AM, confirmed the grievance process was not reviewed through the Quality Assurance Program.
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
Based upon reviews of medical records (#7), Infection Control data/log and interviews the hospital failed to ensure all infections were captured and monitored by Infection Control as evidenced by the failure of Infection Control to identify a patient (#7) with a sputum culture which was positive for Methicillin Resistant Staphylococcus aureus (MRSA). Findings:

Review of patient #7's medical record revealed a physician's order, dated 01/04/11, for a sputum culture. Review of laboratory reports revealed the sputum culture was reported as positive for MRSA and Stenotrophomonas maltophilia.

Review of Infection Control data/log revealed patient #7's sputum culture, that was positive for MRSA, failed to be captured by Infection Control.

Interview, 12/07/11 at 1:00pm, with S6 Infection Control Registered Nurse (RN) confirmed the above information was correct. When S6 was questioned as to why the MRSA positive sputum culture was not captured through the established indicators for MRSA, she replied that she had assumed the role of Infection Control RN in September 2011; therefore she could not answer why the previous Infection Control RN did not capture all the infections including the one on patient #7 (positive sputum culture for MRSA).

Interviews, 12/07/11 at 1:00 pm, with S2 Director of Nursing and S6 Infection Control RN confirmed patient #7's sputum culture results were positive for MRSA and were not captured and reported through Infection Control.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based upon review of the grievance policy and procedure, grievance log, 1 of 10 sampled patients (#6), and staff interview, the hospital failed to ensure the written notice of the outcome of the complaint investigations contained 1) the steps taken on behalf of the patient to investigate the grievance, the results of the process and the date of completion. Findings:

Review of the policy titled "Patient Complaint and Grievance", policy #Adm.005 revealed 4. Grievances/Significant complaints...5. The Grievance Committee will respond to the grievance with written notice by Certified Mail to the patient and/or their legal representative within seven (7) days of receipt of the grievance. The notice shall include: The name of the hospital contact person; The steps taken on behalf of the patient and/or legal representative to investigate the grievance; The results of the grievance process, and ; The date of completion of the process.

The grievance log was reviewed and a sample of patient complaints were selected. On 01/02/2011, pediatric patient #10 presented to the hospital's Emergency Department accompanied by the mother and grandmother. According to the complaint, the patient was administered an adult dose of an antibiotic instead of a pediatric dose. According to Risk Manager S10, the incident was investigated and a letter was sent to the complaint on January 5, 2011. Review of this letter revealed the notice failed to include 1) the steps taken on behalf of the patient and/or legal representative to investigate the grievance, the results of the grievance process, and the date of completion.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon reviews of medical records, Infection Control data/log, Quality Assurance/Performance Improvement Program/meeting minutes, and interviews the hospital failed to ensure the established indicators for Infection Control were captured and reported as evidenced by a patient (#7) who had a positive Methicillin Resistant Staphylococcus aureus (MRSA) sputum culture and the failure of the Infection Control Personnel to capture and report this to the hospital's Quality Assurance Committee. Findings:

Review of patient #7's medical record revealed a physician's order, dated 01/04/11, for a sputum culture. Review of laboratory reports revealed the sputum culture was reported as positive for MRSA and [DIAGNOSES REDACTED].

Review of Infection Control data/log revealed patient #7's sputum culture, that was positive for MRSA, failed to be captured by Infection Control.

Interview, 12/07/11 at 1:00pm, with S6 Infection Control Registered Nurse (RN) confirmed the above information was correct. When S6 was questioned as to why the MRSA positive sputum culture was not captured through the established indicators for MRSA, she replied that she had assumed the role of Infection Control RN in September 2011; therefore she could not answer why the previous Infection Control RN did not capture all the infections including the one on patient #7 (positive sputum culture for MRSA).

Interviews, 12/07/11 at 1:00 pm, with S2 Director of Nursing and S6 Infection Control RN confirmed patient #7's sputum culture results were positive for MRSA and were not captured and reported through Infection Control.