HospitalInspections.org

Based on review of the hospitals' policy/procedures, record review and interview, the hospital failed to ensure that the grievance process was complete by failing to issue a written decision on the grievance to the complainants for 4 of 4 grievances reviewed (R1, R2, R3, R4) out of a total sample of 9 patients.
Findings:

Review of the hospital's policy 8789457 titled, Patient and Family Grievances revealed in part: Management, provides the patient with a written notice of the decision (not to exceed 30 days). The notice will contain the following: Name of the hospital contact person; Steps taken to investigate; Results of investigation, as appropriate; and Completion date.

Review of Patients R1's Grievance Investigation dated 08/20/2021 failed to reveal a letter detailing the results of the investigation was sent to the patients.
Review of Patients R2's Grievance Investigation dated 10/06/2021 failed to reveal a letter detailing the results of the investigation was sent to the patients.
Review of Patients R3's Grievance Investigation dated 08/15/2021 failed to reveal a letter detailing the results of the investigation was sent to the patients.
Review of Patients R4's Grievance Investigation dated 09/13/2021 failed to reveal a letter detailing the results of the investigation was sent to the patients.

In an interview on 11/08/2021 at 2:09 p.m., S2DON acknowledged a written notice detailing the decision of the grievances had not been sent to Patients R1, R2, R3 and R4.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.
Findings:

Observation on 11/09/2021 at 9:30 a.m. revealed the hot water did not work in room "a".

In an interview on 11/09/2021 at 9:45 a.m., Patient #2 stated he has not had hot water in his sink since he arrived. Review of Patient #2's medical record revealed an admit date of 10/25/2021. Patient #2 continued to state he first reported the problem to a nurse and later reported the problem to S5PT.

In an interview on 11/09/2021 at 12:10 p.m. S5PT acknowledged Patient #2 reported on 11/05/2021 his hot water was not working and S5PT stated he reported the problem to S1Administrator.

In an interview on 11/09/2021 at 1:14 p.m., S1Administrator acknowledged that S5PT had reported Patient #2's hot water was not working. S1Administrator continued to state she thought a work order had been submitted and would verify this with S4Maintenance.

In an interview on 11/09/2021 at 1:34 p.m., S1Administrator stated she spoke with S4Maintenance and a work order to repair the hot water had not been submitted for room "a".