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SALEM HOSPITAL 890 OAK STREET, SE SALEM, OR 97301 Oct. 28, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interviews with hospital staff, the review of policies and procedures and documentation for 3 of 5 patients that submitted a verbal or written grievance with the hospital (Patient #s 8, 12, and 13), it was determined that the hospital failed to provide each patient with written notice of its decision containing all of the required elements; the grievance documentation lacked the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital's grievance policy did not include the requirement that the written notice to the patient would include the date of completion.

Findings include:

A policy titled "Resolution of Patient Complaints/Grievances," effective 12/2009 was reviewed and reflected "Grievances - do require written responses at the conclusions of investigations--a written letter, e-mail, fax or a verbal communication, post discharge, from a patient or legally authorized representative expressing concern is always considered to be a grievance, although, if written on a patient survey, it is only considered to be a grievance if there is an accompanying request for resolution, or if the issue raised would normally be considered to be a grievance; an issue raised during care, which is not resolved by 'staff present,' (Manager, Supervisor, Patient Advocate, etc.), is also considered to be a grievance...Written responses to Grievances...The assigned manager shall send a written response for the patient or legally authorized representative raising the initial grievance to receive within seven (7) business days...the letter must provide adequate information to address the following: 1. An apology; 2. The name of the hospital contact person; 3. The steps taken on behalf of the patient to investigate the complaint-although the written response is not required to have an exhaustive explanation of every action taken to investigate and resolve the grievance; 4. The results of the investigation and grievance process; and 5. A decision regarding a claim..." The hospital's grievance policy did not include the requirement that the written notice to the patient would include the date of completion.

1. Grievance documentation for Patient #8 was reviewed and reflected "Submission Date: 02/14/2011" and "Specific Incident Type: failure to follow order." The documentation revealed that the patient reported dissatisfaction with his/her physical therapy during the patient's hospital stay. On 02/23/2011 the documentation reflected "Followup Notes: RN states Patient was unhappy with Physical Therapy...[Patient] stated [he/she] distrusted this therapist..." and Status: Under Review." On 04/05/2011 the documentation reflected "Followup type" and listed Chart Review, Clarification, Investigation, Meeting-Employee/Affiliate, and Meeting-Patient/Family. "Followup Notes" reflected "...met with patient the following day to discuss...Met with contract therapist involved...Went back to see patient again after change in therapist and [plan of care], patient reports being pleased with the outcome and new therapy plan." The documentation did not specify the length of time from the initial complaint to the reported outcome in order to determine whether or not the complaint was resolved promptly at the time of the complaint by staff present. None of the documentation included that the hospital provided the patient with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

2. Grievance documentation for Patient #12 was reviewed and reflected "Submission Date: 09/02/2010" and "Specific Incident Type: Grievance...Reported By Type: Family/Parent/Guardian." Further review of the documentation revealed the patient's [family member] reported dissatisfaction with the patient's physician during the patient's hospital stay. A written response was attached to the grievance, however the response was not addressed to the patient or the patient's [family member].

An interview was conducted with the Accreditation Administrator on 10/28/2011 at 1000. He/she acknowledged that the documentation was a grievance and required a written response. He/she reviewed the letter which was attached to the grievance and acknowledged that it did not pertain to Patient #12. He/she attempted to locate a written response that had been provided to Patient #12 or the patient's [family member]. No further documentation was received for the duration of the onsite survey which was completed on 10/28/2011 at approximately 1500.

3. Grievance documentation for Patient #13 was reviewed and reflected "Submission Date: 05/12/2011" and "Specific Incident Type: Grievance." Further review of the documentation revealed the patient submitted a written grievance that included dissatisfaction with his/her care during a hospital stay. A written response to the patient was attached to the grievance and reflected "...I wanted to assure you that I have been following up on the concerns that you wrote down to help prevent this from happening again in the future," however the response lacked documentation that included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This information was reviewed with the Accreditation Administrator on 10/28/2011 at 1100.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of policies and procedures and review of patient records, it was determined that the hospital failed to meet the ongoing needs of the patient and comply with written physician orders for 1 in 5 inpatients (Patient #9). Findings include:

1. Review of a policy titled "Salem Health Clinical Housewide Policy and Procedure, Process for Planning & Providing Care," last revised 07/11, reflected 1. Assessment A. Each patient will be assessed by an RN; however, other members of the healthcare team may collect data that the RN reviews and utilizes to establish the plan of care...2. The RN analyzes the data, in collaboration with the physician and other heath professionals, to determine and prioritize patient care needs...III. Implementation...A..1. The RN coordinates care provided by the team...B. Documentation of care activities will be done on the Documentation Flow Sheet."

2. Nursing service must ensure that patient needs are met by ongoing assessments of patient's needs, there must be enough staff to ensure physician orders are followed and documented. Review of Patient #9's record reflected the following:

On 05/24/2011 at 1830 the MD ordered "Apply sequential compression device (SCD)."
On 5/25/2011 at 2045 the MD ordered "1. Please forward flush [drain] with 5 cc's NS flush every 8 hrs..."

Patient record review reflected a lack of nurse documentation of the initial application of SCDs. However, the record reflected the SCDs were removed 05/25/2011 at 0834 (fourteen hours after the physician order was written). Documentation reflected that SCDs were in place on 05/25/2011 at 1458 and 2315. The next documentation of SCDs was 05/26/2011 at 0926 (over 10 hours later) when the RN documented "Bilateral: Calf: On." The record lacked documentation for SCD usage again until 05/27/2011 at 1641 (over thirty-one hours later).

The Jackson-Pratt drain was initiated on 05/25/2011 at 2130. Nurse documentation reflected the drain was flushed on 05/25/2011 at 2200. The next documented flushes were 05/26/2011 at 0900 (eleven hours later), 05/26/2011 at 1200, and 5/27/2011 at 0048 (over twelve hours later).