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Based on review of documentation, interviews and review of the Complaint filed with the Hospital, the hospital failed to ensure that a process was established to achieve prompt resolution of patient grievances.

Findings included:

1) Review of the complaint indicated the "green sheet", (which is the paper the complaint is written on), was filed as having occurred on 5/24/10 and the date received as 6/4/10. However, considering the Patient was admitted on 5/28/10, the date of occurrence is incorrect. Additionally, interview with the Director of Marketing indicated she received the complaint a few hours after the Patient was discharged on 6/3/10, so the date received is also incorrect.

2) Review of the green sheet indicated that several issues were presented in the complaint. The sections titled: investigation, resolution and follow-up were never completed by the first floor Nurse Manager.

Additionally, the sections indicated time frames for the investigation of the complaint: 1) the investigation "must be completed by Director/Clinical Coordinator or Rehab Supervisor within 24 hours" and 2) the resolution indicated they "must contact family within 48 hours".

3) The Nurse Manager of the first floor was interviewed in person on 6/30/10 at 9 am. The Nurse Manager said she never interviewed the clinicians involved in the incident because she felt the documentation was substantial. The Nurse Manager said she never contacted the Complainant. The Nurse Manager said she conducted an investigation, but never completed green form to document her findings.

4) Review of the Administration Policy for Patient/Family Complaints, Section VI. Implementation - Department Manager/Designee, Point 6 indicated they must submit all completed incident reports, green patient/family complaint form, pink employee occurrence form, all corresponding documents and a summary of the investigation and action plan to the Risk Manager within 24 hours [underlined for emphasis in the policy] of event or receipt of complaint.

Point 6 was not done by the Nurse Manager of the first floor, thereby causing a delay of 27 days in taking appropriate corrective actions and responding to the Complainant.

Point 9 indicated that the Manager must report back to the patient/family the corrective action plan, resolution or determination reached regarding the incident or complaint and elicits their feedback. If dissatisfied with the explanation, corrective action plan or resolution, the patient or the patient's representatives will be informed that they may wish to refer the problem to Senior Manager responsible for that department. The Senior Manager in collaboration with the Department Manager and Risk Manager will conduct a review of the investigation and corrective action plan within 24 hours and if necessary, meet with the patient/family within 48 hours to review the final determination, corrective action plan and/or resolution.

Point 10 indicated the Manager will schedule a unit based peer review of any/all serious incidents/complaints when appropriate. They will implement recommendations regarding changes in unit based policy/practice and will forward recommendations regarding changes in hospital wide policy/practice to the appropriate Senior Manager.

Points 9 and 10 were not completed.

Based on review of the Hospital Administration Policy regarding Patient/Family Complaints, the Hospital failed to ensure that in its resolution of the grievance, the complainant received written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient taken to investigate the grievance, the results of the grievance process and the date of completion.

Findings included:

1) Review of the Hospital's complaint form, the green form, indicated that although a time frame of 48 hours was specified in which the family had to be contacted, there was no specifications that the contact had to be in writing.

2) Review of the Hospital Administration Policy regarding Patient/Family complaints indicated that there were no criteria regarding providing the Complainant with as written response as required per Federal Regulations and within a reasonable time frame.

Based on review of documentation, interviews, interviews with current inpatients, review of the past six months of complaints filed and observations of care provided by nursing staff, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient.

Findings included:

1) The Complainant said that the Patient had been complaining about waiting for hours for nursing staff to answer the call bell. The Complainant thought the Patient was exaggerating, so the comment was not taken seriously, until one evening, during a visit, it was noted that the Patient waited for at least half an hour after pushing the call button for help and no one had come to the room. The Complainant said that the nurse at the nursing desk was asked to come and help the Patient. The Complainant said the nurse came to the room and taped the call bell and told them to push very hard. The Complainant said the Patient was very weak and could not push the button that hard.

2) A tour of the first floor patient care unit was conducted on 6/30/10 at 9 am. Three patients were randomly selected to interview.

Patient #2

Patient #2 had been admitted for surgical repair of a broken hip and had been in the hospital for two days. Patient #2 was noted to have a brand new nurse call button the workmen had just installed. Patient #2 said the nurses do not answer quickly enough when she needs to use the bathroom. Patient #2 said she had urinary frequency and since she had broken her hip, it was hard to wait for help to get to the bathroom. Patient #2 said she had to go to the bathroom fast. Patient #2 said the staff answer the call bell over the loudspeaker and then you tell them what you need, but it takes a long time for someone to actually come and help you.

This Surveyor was informed that Patient #2 had pressed the call bell for help, the button that indicated assistance needed for the bathroom, and this delayed our interview. This Surveyor then returned from two other interviews and the Patient had just returned from the restroom. It was estimated that the Patient had waited at least 15 - 20 minutes for help in going to the bathroom.

3) The complaint log dated from December through June 2010 was reviewed. The complaints for the first floor ranged from 1 to 5 complaints per month. Complaints reached 5 per month in May. Complaints focused on delay in response time to the nurse call bell, rudeness of nurse aides, lack of assistance/help, one nurse telling a patient that other patients were sicker than the person who called for help and needed to wait, one staff was a rough bully, response to call bell greater than 10, 25, 30 minutes in each complaint and one pertaining to lack of help with toileting and incontinence.


4) The Hospital was in the process of installing a new improved nurse call system. However, Patient #2 who had used the new call bell still had not received prompt attention with toileting from the nursing staff.

Based on review of medical record documentation and interviews, the Hospital failed to ensure that all practitioner's orders, nursing notes, reports of treatment, medications records, radiology, laboratory reports, vital signs and other information necessary to monitor the patient's condition were documented in the Patient's medical record.

Findings included:

1) Review of the progress notes dated 6/3/10 at 6:30 PM indicated the Psychiatrist arrived to evaluate the Patient for anxiety and depression. However, documentation indicated the Psychiatrist observed the Patient to have difficulty breathing. Documentation indicated the Psychiatrist asked for a STAT oxygen saturation level and the "best number achieved" was 79% [the Patient's baseline was 88%]. Documentation indicated that the psychiatric evaluation was delayed and the Patient was transferred out for acute care.

The Psychiatrist was interviewed by phone on 7/5/10 at 7:20 am. The Psychiatrist said the Patient was looking very poor at the time he arrived to evaluate her for anxiety and depression. The Psychiatrist said the Patient was on nasal cannula oxygen at the time and he called for a STAT oxygen saturation level to be done. The Psychiatrist said the Respiratory therapist was called STAT and he came within minutes to treat the Patient.

The medical record did not contain documentation by the Respiratory Therapist regarding the stat acute care consultation requested by the Psychiatrist.

2) The Respiratory Therapist was interviewed in person on 6/30/10 at 2:10 PM. The Respiratory Therapist [RT] said he received a call around 6 PM from the Nurse regarding the Patient having breathing trouble and he came to the unit right away. The RT acknowledged that he did not document the incident in the Patient's medical record

3) The RT said he recalled having given the Patient a breathing treatment around 5 PM that evening before the acute decline in the Patient's condition. The RT acknowledged he also did not document the breathing treatment he administered to the Patient at 5 PM on 6/3/10.