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CHI ST LUKES HEALTH MEMORIAL LUFKIN 1201 WEST FRANK STREET LUFKIN, TX 75901 June 3, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview the facility failed to protect 1 of 1 (patient #1) patient rights. The facility failed to follow their own policy related to responding to patient/family concerns. The facility also failed to follow their policy for reporting incidents/accidents. Wife of patient #1 reported to staff #5 that her husband may have received an injury while being transferred from the patient's bed to the bedside commode. The wife reported to staff #5 the injury may have led to the patient having to have additional surgery.
A phone interview was conducted with patient #1's wife at 12:00 pm on 05/30/2014. The patient's wife revealed she did not make a formal complaint to the hospital in regards to concerns of how patient #1 had been transferred to the bedside commode. The patient's wife stated she had mentioned the incident to staff#5 but had not heard anything from the facility.
On 6/02/2014 at approximately 10:30 am an interview was held with staff #6, the Risk Manager, in the Administrative Conference Room. The risk manager provided an e-mail communication from staff #7 to staff #6 regarding the incident. No other evidence was provided of a follow up regarding patient #1's incident.
A review of the e-mail from staff #7 to staff #6 revealed; "I spoke to staff #9, PCT Calder-1 today to inquire if the patient fell or his bottom hit hard on the toilet seat when assisted to the commode. He stated that when he was assisting the patient to the commode, the pt. leg got weak and gave out on him. He was already near the toilet, he had his arm around the patient chest and he assisted in lowering him down to the commode while the patient was also holding on the side bar for support. He lowered him slowly and easy. He and the 2 nurses assisted to put him back to bed."
On 6/02/2014 at approximately 11:30 am an interview was held with staff #5, the Rehabilitation Manager, in the Administrative Conference Room. The interview revealed no incident report had been completed. No other evidence was provided of a follow up regarding patient #1's incident.
On 6/02/2014 at approximately 2:30 pm an interview was held with staff #5, the Rehabilitation Admission Coordinator, in the Administrative Conference Room. The interview revealed staff #5 was told by patient #1's wife, patient #1's return to surgery may have been a result him being improperly transferred to the bedside commode the night of 11/14/2013. Staff #5 revealed concerns were reported to staff #6 Risk Manager and staff #7 Rehabilitation Manager. Staff #5 revealed the daughter of patient #1had called and reported the same concerns (her father's return to surgery may have been a result him being improperly transferred to the bedside commode the night of 11/14/2013). Staff #5 did not complete a written Incident Report or initiate the complaint/grievance process.
A review of policy number 1.012 titled Patient Rights and Responsibilities revealed:
"14. Hospital Resources - The patient has the right to know about health system resources, such as patient representatives, an ethics committee or other health System staff that may help resolve problems and questions about their hospital stay and care.
a. (The facility name) regards all patient/family concerns or complaints as significant. The patient is entitled to information about the health system's mechanism for initiation, review and resolution of patient complaints. Appropriate action is taken on every concern.
b. The patient and/or legal guardian have the right to present complaints, and receive a response from Administration which addresses the complaint.
c. The patient has a right to file a grievance with hospital representatives. IV. Assisting Patients in Exercising Their Rights
A. It is expected that all health system employees and medical staff will assist patients in asserting their rights.
B. Patient Relations
1. An Administrative representative will serve as a liaison between the patient and services rendered and will seek solutions to problems, concerns and unmet needs an behalf of the patient. Patient concerns must be addressed upon receipt. The department director or unit manager is ultimately responsible for resolving all problems except those involving policy waivers. Employee orientation facilitators will help sensitize new health system employees through orientation on the needs of the patient and their families and will reinforce the right of every patient to considerate and respectful care.

A review of policy number 1.099 titled "Administration- Patient Comment/Complaint Policy" revealed "POLICY: To ensure that hospital personnel are notified appropriately of patient complaints, with the goal of handling all complaints in a timely and professional manner with appropriate resolution provided to patient or family member by staff present .....
Definitions:
Complainant - A patient or patient's representative. Complaints cannot be initiated by a representative of MHSET. A patient advocate may be accessed by the complainant to assist with complaints and grievances. Complaint - An issue expressed by a complainant that is resolved to the patient's satisfaction by staff present. Resolution must be within a 24 hour period and be complete. This will include displeasure with a process or person or dissatisfaction with some aspect of care/service.
Grievance - Any complaint that is not resolved to the patient's satisfaction by staff present or resolution is not complete within a 24 hour period. This will include issues with a real or perceived violation of patients' rights or a serious complaint in which the intent is to improve the clinical process related to patient care.
Staff Present-Any hospital staff present at the time of complaint or who can quickly be at the patient's location to resolve the patient's complaint.
PROCEDURE: INVESTIGATION OF COMPLAINTS/GRIEVANCES
Immediately after the receipt of a complaint, the complaint will be evaluated by the context of the grievance definition. If the complaint meets any one grievance criterion, it will be designated as a grievance and is subject to the grievance policy.
1. All grievances will be responded to the complainant in writing within 7 days, even if the response is that an investigation is ongoing.

A review of policy number 1.150 titled Incident and Injury Reporting revealed; POLICY: Each Department Director will be responsible for reporting accidents or incidents which are not work related within their respective departments. The Director will submit an Incident Report Form.
A. If a patient is involved in an incident, the patient's physician shall be notified.
B. Incident reports concerning patient care and nursing service shall be sent to Risk Management by the end of the shift in which the incident occurs.
C. Incident Reports generated in other departments will be sent to Risk Management as soon as possible but within at 24 hours of the incident occurrence.
D. Incidents or occurrences that involve actual or potential substantial impact on the health and safety of the individual shall be reported to the Department Manager or Supervisor immediately. These incidents/occurrences shall be reported to the Risk Manager as soon as possible.
A review of policy number HP 250.17 titled Incident Reports revealed; PURPOSE: An Incident Report will be written factually and confidentially for any adverse occurrence of unexpected outcome that causes injury or harm or the potential for injury or harm to a patient or visitor. Record factual patient care, information in the Medical Record, but do not mention that an incident report has been filed as this destroys confidentiality. Do not state blame, guilt, or fault regarding the adverse occurrence. Any employee or staff member with knowledge of adverse occurrence may use the report. Confidentiality must be maintained .....
RESPONSIBILITY OF:
Registered Nurse
Licensed Vocational Nurse
Patient Care Tech
Unit Secretary
Physicians
Ancillary Personnel involved in patient care
1. PROCEDURE:
A. Identify the adverse occurrence. Assess the nature of injury. Provide care necessary to stabilize/control injury and follow-up care. Notify the physician. If the victim is a visitor, advise and take visitor to emergency room .
B. Fill out the Incident Report form stating facts of occurrence and assessment of injury. Document in the chart pertinent patient information, assessment, treatment
II. KEY POINTS TO REMEMBER:
E. The person who first becomes aware of the adverse condition should initiate the report.