HospitalInspections.org

Based on document review and interview, the facility failed to ensure a complainant was notified of a plan of action and provision of a written response to a grievance for 1 of 1 grievance reviewed. (Family member #1)

Findings include:

1. Facility policy titled "Patient Complaint/Grievance Management" last reviewed/revised 5/29/19 indicated the following: "...PURPOSE: The purpose of this policy is to: 1. Provide a standardized process to manage and resolve complaints/grievances received by the hospital. 2. Provide a process to review, investigate, and resolve a patient's/patient representative's complaint/grievance within a reasonable time frame. 3. Provide a process to determine the effectiveness of the complaint/grievance process through quality improvement monitoring to help identify, investigate and resolve any deeper, systemic problems indicated by the grievance analysis. POLICY: 1. Patients have the right to express concerns and expect resolution in a timely manner...5. The hospital's Performance Improvement Committee ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within seven days of the hospital's receipt of the grievance, even though the hospital resolution need not be completed within the seven-day limit. The written notice shall contain the following: a. Name of the Hospital contact person; b. Steps taken on behalf of the patient to investigate the grievance; c. Results of the grievance process; and d. Date of completion..."

2. A review of an event report for a grievance related to Patient #1 with a report date of 10/12/20, indicated a grievance was received on 10/12/20 via email from Family Member #1. The following was indicated:
A note dated 10/20/20 indicated the following: "...received a medical record request from [Family Member #1] requesting we send [Patient #1's] medical record to the...Law Firm. [Rehab] quality director notified, HIM [Health Information Management] director notified...will stop communication to [Family Member #1] until further notice.
The event report lacked documentation of Family Member #1 being provided a plan of action or provision of a written response.

3. During an interview with A3 (Director of Quality/Risk) and N4 (Chief Nursing Officer) on 5/18/21 at 3:57 p.m., they verified that Family Member #1 was not sent a written notice of receipt, investigation and outcomes regarding a grievance related to Patient #1's care at the facility within seven days of the hospital's receipt of the grievance due to Family Member #1 retaining legal counsel.

Based on document review and interview, the facility failed to ensure nursing staff notified the physician of a change in patient condition for 1 of 10 medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Change in Patient Condition Process" last reviewed/revised 8/2020 indicated the following: "PURPOSE: To improve access, experience and outcomes for inpatients with potential or acute need for critical care; promote collaboration and communication between care areas; facilitate appropriate transfers to Emergency Room and assist nurse in planning interventions when a patient has symptomatic changes in condition...POLICY...D. The physician/allied health professional will be notified in a timely manner of any concerns...GUIDELINES FOR WHEN TO USE THE CHANGE IN PATIENT CONDITION PROCESS...E. Significant change...neurological status...ROLE OF THE CPC [Change in Patient Condition] PARTICIPANTS...C. Communicate assessment findings to the physician/allied health professional and make recommendations for appropriate intervention(s)...DOCUMENTATION...physician/allied health professional communication shall be documented in the patient's medical record by the department staff..."

2. Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 8/21/20 at 2:42 p.m.

(B) A review of a "Physical Therapy Daily Progress Note" dated 8/29/20 from 8:30 a.m. to 9:00 a.m., indicated the following: "...Assessment/Plan...Patient's response to treatment...patient concerned with vision on right thinking [it's] causing [his/her] nausea, gave patient eye patch, and stated if it didn't help to take it off later...Communication with other disciplines...RN [Registered Nurse]..."

(C) A review of a "Physical Therapy Daily Progress Note" dated 8/29/20 from 2:30 p.m. to 3:00 p.m., indicated the following: "...Subjective...patient nauseated, nursing notified. [Patient] states its mostly when [he/she] is watching [television].

(D) A review of a "Nursing Shift Assessment" dated 8/29/20 from 6:00 a.m. to 7:00 p.m., indicated the following:
"...Neurological Assessment...Visual/perceptual function...Blurred vision..." The medical record lacked documentation of Physician notification of Patient #1's blurred vision.

(E) A review of a "Nursing Shift Assessment" dated 8/29/20 from 6:00 p.m. to 6:30 a.m., indicated the following:
"...Neurological Assessment...Visual/perceptual function...Blurred vision, eye patch, right eye..." The medical record lacked documentation of Physician notification of Patient #1's blurred vision.

3. During an interview with MD1 (Doctor of Medicine) on 5/18/21 at 3:05 p.m., MD1 verified that he/she was not notified of Patient #1's blurred vision.

4. During an interview with A4 (Network Health Information Management Manager) on 5/18/21 at 5:20 p.m., he/she verified the medical record information for Patient #1.