HospitalInspections.org

Based upon record review and interview, the hospital failed to ensure each patient and/or the patient's representative was provided information related to the grievance process. This was evidenced by the hospital's failure to 1) provide each patient the information on whom to contact to file a grievance, and 2) make available to the patient the phone number and address to lodge a grievance with the State Agency. Findings:

Review of policy POL859 Titled Patient Grievance 5.0 Procedure: 5.1 Upon admission, each patient is given a copy of the Patient Rights.

Interview with S2RN/DON (Registered Nurse/Director of Nursing) on 6/7/16 at 9:30 a.m. revealed when asked about the grievance process, he stated upon admission each patient was provided a packet of information related to the process and how to file a complaint. After reviewing the packet S2RN/DON was asked where the grievance information was located and identified the Quality Improvement Organizations (Medicare) was to be contacted for filing a complaint. Review of the QIO information revealed this was for filing an appeal for premature discharge.

Further interview with S2RN/DON revealed after explaining the QIO was not related to the grievance process, he provided another form and stated this would be given to the patient if they wanted to file a complaint. This form failed to identify the grievance process and who to contact to file a grievance. The information at the bottom of the form identified the state agency to contact; however, this form was not provided to the patient unless they wanted to file a complaint.

Based upon record review and interview, the hospital failed to ensure the nursing care plan was individualized and based on the patient's needs. This was evidenced by the review of 7 of 7 open and closed medical records (#1-#7) in which the plan of care contained the same short term goals and interventions. Findings:

Review of closed medical records #1 through #4, and open medical records #5-#7 revealed the short term treatment goals were 1) Will remain hemodynamically stable; 2) Will be free from falls; and 3) Pain level will be between 0-4 (scale 0-10). The pre-printed interventions were identified and all were the same for each patient.

Interview with S2RN/DON on 6/7/16 at 3:00 p.m. revealed when asked about the nursing care plans being the same for patient #1-#7, he responded that he had new nursing care plans but they had not yet been implemented.