HospitalInspections.org

Based on record review and interviews, the hospital failed to track patient complaints during a July 2015 facility utility failure of the air conditioning system, in that, patient complaints were found on the Supervisor's report and during interviews with staff which had not been logged/processed/tracked as complaints in the hospital's system/process.

Findings Included

The 06/01/2015 through 07/09/2015 complaint and grievance log was reviewed. There were no logged complaints or grievances for the A/C - heat episode or the additional complaints found during the survey.

The 06/01/15 through 07/09/2015 incident report log was reviewed. There were no logged issues related to the A/C - heat episode or the additional issues found.

The Supervisor report reflected complaints without resolutions that were not logged as a complaint/grievance or incident. These included: "06/06 (2015) (Patient #10's name)...C/O of AC (complaint of air conditioning) not working...07/08 (2015) (Patient #6's name)...Clinitron bed temp > 104°, automatic shutoff, pt (patient) got up to w/c (wheelchair) until bed came back on...07/08 (2015) (Patient #22's name)...C/O heat in room, multiple fans provided...07/08 (2015) (Patient #13's name)...son upset about the heat...07/09 (2015) (Patient #9's name)...spouse unhappy with A/C situation in room..."

During an interview in the conference room on 07/09/2015 at 4:12 PM, Personnel #3 was asked if they had received any complaints about the heat. Personnel #3 stated, "Not that I am aware of."

During an interview on 07/09/2015 at 7:15 PM, Personnel #2 was asked about the complaint and grievance log not listing any patient complaints about the heat. Personnel #2 stated, "We were providing proactively the spot coolers, fixing the air conditioner and giving them ice to help. We were doing what we could to make it better." Personnel #2 was asked what the patient complaint becomes if the issue is not fixed or the patient was not happy with the hospital's efforts. Personnel #2 stated, "A grievance." Personnel #2 was asked about the reporting of the air conditioner/ heat issue for the patients. Personnel #2 stated there had not been a patient complaint or incident report completed for the issue.

During an interview in the conference room on 07/10/2015 at 10:49 AM, Physician #1 was asked if he had been told of patient complaints about the heat. Physician #1 stated, "No."

During an interview on 1 South on 07/10/2015 at 1:55 PM, Personnel #11 was asked about the complaint and grievance process and how complaints are put in. Personnel #11 stated, "Through the computer system and administration takes care of it." Personnel #11 was asked if she put in any patient complaints for the heat issue. Personnel #11 stated, "I didn't think about it. Everyone was going through it. You are right. I didn't put in a patient complaint for it."

During an interview on 1 South on 07/10/2015 at 2:10 PM, Personnel #10 was asked about the complaint and grievance process. Personnel #10 stated, "If there was an issue, then we put it into Protouch (Electronic Medical Record). Personnel #10 was asked if she put patient complaints of the heat into Protouch. Personnel #10 stated, "No."

During an interview on 1 South on 07/10/2015 at 2:45 PM, Personnel #8 was asked about the complaint process. Personnel #8 stated if a patient complained she would notify her manager. Personnel #8 was asked if she notified her manager of the patient issues. Personnel #8 stated, "No."

The August 2014 "Event Reporting System" policy required, "all patient and visitor events be reported...an event is defined as any occurance or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients, visitors...threat to patient safety...patient dissatisfaction...personnel are responsible for reporting...timely...enter the event into the Event Reporting System...no later than 24 hours...DQM (Director of Quality) shall complete the event investigation within 3 days...reported to the Quality Council..."


The January 2015 "Strategic Quality Plan" required, "Compliance with mandatory reporting requirements including strict adherance to standardized processes, definitions and time frames for submission of accurate and reliable data...core operational responsibility for every executive and every person providing and supporting care in our hospitals to ensure an environment where care is safe...patient safety and error reduction rates...identify safety issues, concerns, errors...proactively identify and reduce patient safety risks..."