HospitalInspections.org

Based on medical records, hospital policy and staff interviews, the hospital failed to ensure an effective grievance process was in place. The deficient practice is evidenced by the facility failing to investigate a patient's grievance for 1(#5) of 5 sampled patients and failing to notify the patient of the grievance resolution for 1(#2) of 5 sampled patients.
Findings:

Patient #5

Review of Hospital's Policy named Patient Grievance revealed, in part, the following:
2.1.1 A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. If a complaint cannot be resolved promptly by staff present or is referred to a patient advocate, or hospital management, it is to be considered a grievance.
2.13 The grievance committee will investigate, review grievance related documentation and formulate an appropriate resolution. The grievance resolution will be sent in writing to the patient or the patient representative. 2.15 If the grievance is not resolved, the investigation is not complete ...another written response shall be given to the complainant within 30 days.

Review of Patient #5's Medical Record revealed an admit date of 6/21/18.

Review of Patient #5's Discharge Summary revealed the patient and her family elected to leave AMA (Against Medical Advice) on the day of admission.

During an interview on 8/1/18 at 11:20 a.m., S1DON (Director of Nursing) stated that the grievance process should be followed for any patient that leaves AMA.

During an interview on 8/1/18 at 11:35 a.m., S1DON and S3RN (Registered Nurse) Case Manager confirmed a Patient Grievance was not initiated for Patient #5 and there was no contact with the patient following their discharge.

Patient #2

Review of Patient #2's Medical Record revealed an admit date of 5/29/18 and the patient was discharge 6/6/18.

Review of Patient #2's Incident Report dated 6/6/18 at 3:30 p.m. revealed, in part, the following: Fall with fracture. Description - During standing ball toss patient instructed to static stand and toss ball. Therapist had gait belt and had a hand on patient. Patient impulsively stepped forward and had a loss of balance, which resulted in fall. Therapist guided patient to ground. MD notified. Husband notified.

Review of hospital documents revealed Patient #2's initial grievance letter dated 6/8/18 stated the hospital, after review of patient #2's stay, would send a letter detailing their findings within 30 days.

Further review failed to reveal Patient #2 was notified of the resolution or findings regarding their grievance.

During an interview on 8/1/18 at 11:40 a.m., S1DON and S3RN Case Manager stated a letter detailing the hospital's findings regarding the grievance from 6/6/18 was not sent to Patient #2.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well- being of patients was assured.
Findings:

Observation upon entrance on 7/30/18 revealed a cricket crawling along the floor next to the nurse's station.

During an interview on 7/30/18 at 5:00 a.m., S2RN (Registered Nurse) Charge Nurse acknowledged the cricket and stated six of the twenty-four patient rooms were blocked and not being used due to ongoing construction and that the crickets have been a problem since the construction began.

Observation on 7/30/18 at 5:00 a.m., accompanied by S2RN Charge Nurse, revealed the following:

Room b had used personal hygiene items remaining on the shelf in shower stall; 2 dirty plastic wash basins on the shower floor; Shower chair soiled/dirty; Dirty wheelchair and walker stored in the room designated as clean. S2RNCharge Nurse acknowledged the dirty patient use items and dirty patient care equipment.

Room j had a dirty bedside toilet and walker in the patient's room and a dirty shower chair and bedside commode in the bathroom. Further observation revealed an upholstered chair with tears/rips to the vinyl covering.

During an interview on 7/30/18 at 5:20 a.m., S2RN Charge Nurse acknowledged the tears/rips on the chair and the dirty patient care equipment stored in the patient rooms, which were designated as clean.

Observation on 7/30/18 at 9:50 a.m., accompanied by S1DON (Director of Nursing), revealed ants crawling on the window seal in room b.
S1DON confirmed the ants that were crawling on the window seal in room b.

Observation on 7/31/18 at 9:25 a.m. revealed a pair of wheelchair legs stored on top of the patient's bedside commode in room d.

Observation on 7/31/18 at 9:30 a.m. revealed a hole in the wall approximately 8 cm in size located on the left side of the A/C unit in room c.

Observation on 7/31/18 at 9:45 a.m. revealed the patient's pillows were stored on the top of the trashcan in room e.

Observation on 7/31/18 at revealed the exit door on the 150's hall was functional and the S1DON exited through the doorway.

Observation on 7/31/18 beginning at 3:20 p.m., accompanied by S1DON revealed the following:
Rooms a, c, e, g, h and i had rips/tears to the vinyl covering on the patient's chairs.
Room h had a cricket crawling along the floor of the patient's living area.
Room f had wheelchair legs stored on top of the patient's bedside commode.
Room k had a missing light cover on the wall mounted light located above the patient's bed.
During an interview at this time, S1DON confirmed the findings for rooms a, c, e, f, g, h, i and k.

During an interview 7/31/18 9:45 a.m., Patient #R1's family member stated the R1 had complained to him about crickets in the room but stated there were no other issues or concerns.

During an interview on 7/31/18 at 10:10 a.m. Patient #R2's family member stated he had seen crickets in the patient's room and continued to state the "overall cleanliness had a lot to be desired".