HospitalInspections.org

Based on document review and staff interview, in three (3) of six (6) grievance reports reviewed the Hospital did not implement its policy and procedure to ensure a complete investigation of patients grievances (Patients 17, 18 &19).


Findings include:

Review of the Grievance Reports from March 2017 to June 2017, identified that the hospital's investigation did not address all the allegations made by the complainants.

On 6/16/17, the sister of Patient #17 filed a grievance stating that the patient was given Morphine without their consent and that it was the family's wish not to give this drug to the patient. The sister also stated that she was the patient's Health Care Proxy and no one contacted her.

The investigation report did not address the allegation that morphine was given to the patient without consent of the Health Care Proxy.


On 3/20/17 the daughter of Patient #18, filed a grievance with the hospital making several allegations. She included picture of the injuries her mother sustained after a fall incident in the hospital. The patient's daughter wrote that some of the employees were "negligent and unprofessional", which caused her mother to sustain a blunt head injury, a bruised arm, and a torn rotator cuff."
She also complained that the hospital did not contact the family after the incident and questioned why the hospital "sedated" her mother.

The investigation report did not indicate how the patient sustained the injuries alleged by the complainant.


On 6/8/17, the family of Patient #19 filed a grievance with the hospital complaining that the physician who treated the patient was "rude, impatient, dismissive and irritable." The complainant provided detailed information of what led to the incident.

The grievance file did not document how this allegation was investigated.

Review of the Hospital's Policy and Procedure titled "Grievance Process", last reviewed 12/19/16 notes "All grievances are thoroughly investigated."


During interview on 7/28/17 at 10:25 AM, Staff R, Patient Representative acknowledged the findings and reported that she is responsible for receiving patients' grievances/complaints, and upon receipt, forwards them to the applicable department for follow-up and investigation.

Based on document review and staff interview the hospital did not ensure that:
1. Incidents/Occurrences were accurately tracked.
2. Incidents/Occurrences were investigated and that the data is analyzed to identify areas to improve patient care services.

Findings include:

Review of the Department of Nursing Performance Improvement meetings from February 2017 to June 2017, showed that 6 (six) incidents of falls were reported for March through June; however, the data for the hospital's fall incidents for the same period showed a higher rate of falls than reported.
The data report showed evidence of 15 falls in March through May of 2017.


Review of Incident/Occurrence Reports for January 2017 to July 2017, showed that the hospital documented "brief summary" of incidences/occurrences each month. There was no documented evidence of a complete investigation of these incidents.

For example:
Occurrence Report dated 5/11/7 noted that a patient fell and "was found to have hematoma to back of head."

Occurrence Report dated 6/11/17 noted that a patient fell and was found to have knee swelling.

Occurrence Report dated 6/20/17 documented that a patient was unresponsive on the floor.

Occurrence Report dated 6/23/17 noted that a patient was found unresponsive on the bathroom floor in the waiting area of the emergency room.

There was no documented evidence that these incidents/occurrences were investigated and corrective actions plan was implemented for problems identified.


The Hospital's Policy and Procedure Titled "Incident Reporting and Management Program," last reviewed 3/2017, states that the facility would investigate and take corrective action upon the occurrence of untoward events.

During interview on 7/27/17 at 12:55 PM, Staff B, Associate Director of Risk Management stated that the reports presented to the surveyors were complete and the hospital had no additional information on the investigation of incidents/occurrences. In addition, she reported that information about incidents/occurrences were in the electronic system and was currently inaccessible.