HospitalInspections.org

Based on review of hospital policy, medical records, complaint log, and staff interviews, the hospital staff failed to identify a patient complaint as a grievance per policy in 2 of 2 medical records reviewed. (Patient #2, Patient #17)

Findings included:

Review on 03/08/2023 of the hospital policy "Patient and Customer Complaint or Grievance," last reviewed 06/16/2022 revealed "...PURPOSE To establish guidelines for hospitals to follow in the development of hospital-specific complaint and grievance processes requirements...Patient Grievances ...Complaints meeting any of the criteria below are considered grievances and require a written response: ...2. Complaint regarding the patient's care or with an allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more CoP's (conditions of participation), or other CMS (Centers for Medicare and Medicaid Services) requirements... 5. The patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance ...Patient Grievances - Actions to be taken; The hospital must review, investigate and resolve each patient's grievances within a reasonable time frame and provide a reasonable response...3. A written communication must be sent to the patient,...On average, the written response should be complete within 7 calendar days of receipt of grievance...findings and determination regarding the grievance in a language and manner the patient and/or family understands, written notice of its decision and 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..."

1. Closed medical review revealed Patient #2 was a 52-year-old female admitted on 08/01/2022 following a thoracic back surgery. The History and Physical dated 08/02/2022 at 1249 by Medical Doctor (MD) #1 revealed "...Chief complaint: abnormalities of gait, mobility, and ADL's (activities of daily living), decreased sensation and activity tolerance, impaired posture, balance and sensory processing related to thoracic myelopathy s/p (status post) thoracic (located in the center of our upper back and middle back) fusion (connecting two or more bones) T4-T11 (thoracic vertebrae 4-11) w/ (with) T6, T8, T9 (thoracic vertebrae 6, 8, and 9) laminectomy (surgery in which a surgeon removed part or all of the vertebral bone) on 07/26/2022..." Past medical history included a Pulmonary Embolus (blood clot in the lung). Review of the Physician Progress Note dated 08/03/2023 at 1059 by MD #1 revealed "...Physical Exam: ...Neuro: (Neurological) Less than antigravity strength left lower extremity..." The physical exam on 08/03/2023 by MD #1 revealed Patient #2 had very little movement and weakness of the left lower leg. Review of the Physician Order dated 08/05/2022 at 1552 by Nurse Practitioner (NP) #5 revealed, Ultrasound Left Extremity, Duplex Left, status -routine, for pain in the left leg and at 1553 NP #5 ordered an x-ray of the left tibia and fibula (lower leg bones), status -routine, for pain in lower leg. The x-ray for the left tibia/fibula was completed and resulted on 08/05/2022 at 2049 that revealed "Results: ...No Fracture (break) or dislocation seen. The knee and ankle joints are grossly intact..." The Ultrasound of the Left Leg was completed on 08/08/2022 at 0908 and results revealed "...Conclusion: No deep vein thrombosis seen..." Review of the medical record failed to reveal a provider progress note, nurses note, or documentation referencing why the ultrasound or x-ray of the left leg were ordered. Medical record review failed to reveal documentation referencing Patient #2 had a fall involving a lift or reported leg injury prior to 08/08/2022. The Discharge Summary dated 08/24/2023 at 0858 by MD #2 revealed Patient #2 was being discharged to home with outpatient services and prognosis was good.

Review on 03/09/2023 of the "(Named) Facility Complaint Log" dated 08/08/2022 at 1645 entered by Case Manager (CM) #3 revealed "...Description of Complaint (named) Case Manager....She also had some issues with the lift. I think the sit to stand where she fell out of the lift and injured her leg [sic]. She is very upset that none of the staff apologized when the incident happened....Leadership Follow-up: Has a Manager investigated complaint? Yes.... Manager/Supervisor Comments: DTO (Director of Therapy Operation) went to patient's room to speak to her about her concerns ...2. Sit to Stand Lift: patient fell out of the sit to stand lift while she was being transferred from w/c (wheelchair) to bed...DTO Action: recommend that staff do not use the STS (sit to stand) lift with the patient, staff need to be retrained on how to use the STS lift and which patients the STS lift should and should not be used with. Recommend: +2 (two persons) sliding board transfers or Hoyer lift. (Named signature) at 08/09/2022 at 1624. Considered Resolved: Yes. Resolution Date/Time 08/09/2022 at 1645..." Review failed to reveal if Patient #2 was satisfied with the resolution and failed to reveal an investigation for a fall with lift was completed by the hospital.

Request to interview Nurse Practitioner (NP) #5 who ordered lower extremity x-rays and ultrasound on 08/05/2022 revealed she was unavailable for interview.

Telephone interview on 03/09/2023 at 1304 with Case Manager #3 who received Patient #2's verbal complaint of an alleged fall from the sit to stand lift with lower leg injury revealed "...I remembered what happened was not current, and had happened days before reported to me. I reported to my supervisor and to the nurse..." Interview revealed Patient #2 reported to CM #3 she had had a fall during use of the sit to stand lift with lower leg injury prior to 08/08/2022 and CM #3 had completed an incident report, notified her supervisor, and reported it to the nurse on duty.

Interview on 03/09/2023 at 1416 with the Director of Therapy Operations, DTO #4 revealed "...I asked the patient 'what are your concerns?'. I talked to the therapist involved in the patient's care. Based on what the patient said she had concerns with the sit to stand lift, so I recommended staff just use the regular lift..." DTO #4 failed to investigate a fall with the sit to stand lift with leg injury that was verbally reported by Patient #2 that occurred prior to 08/08/2022. DTO #4 did not identify the complaint with allegation of patient harm as a grievance per policy. Interview revealed the hospital policy for a grievance was not followed for an allegation of patient harm.

Interview on 03/10/2023 at 1024 with facility Director of Quality and Risk (QRD) revealed "...If harm would have been proved, this would have raised the complaint to a grievance that would have been reported to the state...any employee can enter a complaint, then the complaint was sent to the senior leader for review. Only the QRD and CEO have access to change a complaint to a grievance..." The QRD agreed the complaint did have a concern for patient harm and should have been changed to a grievance. Interview revealed hospital policy for a grievance was not followed.






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2. Closed medical record review revealed Patient #17 was a 64-year-old female admitted on 01/05/2023 at 1451 for a chief complaint of "Abnormalities of gait, ADL's (activities of daily living) and mobility, impaired posture, balance, decreased activity tolerance related to gram negative pneumonia with COPD (Chronic Obstructive Pulmonary Disease-a condition involving narrowing of the airways and difficulty or discomfort in breathing), and chronic respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues)." Patient was provided with rehabilitation services and then later on 01/16/2023 at 1340 was discharged to home.

Review on 03/08/2023 of the "(Named)Facility Complaint Log" dated 01/13/2023 at 0810 by Nurse Manager (NM) revealed a documented complaint listed for Patient #17. "Complaint raised on 01/13/2023 at 08:10 ...Complaint raised by-Patient. Received via-verbal. Concern involves-general care ...Description of Complaint- Pt (Patient) has had several complaints about the RNT (Rehab Nurse Technician) care on the night shift but this morning requested a formal complaint to be made. Her complaints include lack of personal care such as getting assist [sic] to bathe, leaving the door open when she was to get dressed, and perceiving the staff angry when she asked for assist [sic]...Action Taken-General reminder for comfort professionalism and respect given during nursing huddle, identification of RNT on duty for night of complaint. (signed by NM on 01/17/2023 at 1429) Considered Resolved-Yes. Resolution Date/Time 01/17/2023 at 14:00."

Interview on 03/10/2023 at 1045 with facility Director of Quality and Risk (QRD) revealed that after she reviewed Patient #17's complaint wording, QRD stated "This should have been a Grievance. Anyone can enter a complaint and any of the leadership can investigate. I get every complaint and only myself or the CEO (Chief Executive Officer) can answer the 'elevate to grievance per policy' question. Going forward, I will have Senior Leaders to read the (Patient and Customer Complaint or Grievance) policy and reference in the writing/resolving. I will personally check every complaint for Grievance criteria."
NC00192148, NC00192071