HospitalInspections.org

Based on interview and record review the facility failed to ensure that prompt resolution of patient ID # 1 complaint/grievance was reviewed and/or resolved.

Findings include:

The facility failed to follow their established process for resolving patient complaints/grievances as evidenced by not sending a signed letter from the facility CEO or designated person; informing patient ID #1 family that, the facility had reviewed their concerns.

Interview with Quality Director ID #65 reported that they became aware of the Patient ID #1 death, and concerns about his care while a patient at Kindred Hospital through a letter the CEO ID # 51 had received from the daughter of the Patinet ID #1. The Quality Director, #65, reported that Joint Commission had told them they had received a letter regarding the same patient ID # 1. She further reported they did not respond back to the complaiant, either by mail or phone call ever, to her knowledge. She reported she did not send a letter, or call the family of the patient.. She stated," we got so caught up in the investigation we just never did send her a letter or anything". Was your CEO aware of the investigation and the letter sent by the daughter, she stated, " yes, he was".

Interview on 3/1/19 at 2:00 pm with CEO ID #51 he revealed when asked if he received a letter from the Patient ID # 1 daughter he responded, "yes". He reported that he gave the letter to his Quality Director ID # 65 what happen after that I do not recall. He responded he could not recall if a letter was sent, or a phone call was made from the facility. He could not recall only to say he turned it over to his Quality Director.

Record review on 3/1/18 of facility policy titled: Patient Complaint/Grieveance Process, dated 06/2017 reads:
POLICY
... 2. The Governing Board has delegated the Complaint and Grievance process to the Hospital Quality Council or designated subcommitte. The Quality Council has designated specific responsibilities to the following roles:
a. CEO/Administrator: Retains responsibility for complaint and grievance process...

PROCEDURE
5. DQM Responsibilioties
h. Once the investigation is complete:
...V. Complete review to ensure:
1. The compliant or grievance is reported promptly
2. Investigation was appropriate
3. Timely patient and or family communication
...I. Once an action has been taken:
i. Assure the complaining party is aware of the investigation results and actions taken.
ii. ... This communication should be made by the CEO or their designee (CCO, DQM, Department Manger,etc)
iii. Ask whether or not the patient or complainant considers the matter resolved.
... L. Send the final CEO letter as soon as:
i. The investigation is completed and the issue is resolved

Based on observation, interview and record review the facility failed to manitain written orders that were dated, timed, signed and legible in accordance with the facility policy and State law.

Findings include:

Review of 7 of 7 order enteries in medical record ID #1 contianed incomplete orders as evidenced by:
7 of 7 orders did not have legible signature, and (5) of (7) orders only signed off as "noted". Five (5) of (5) orders were not timed as taken off/transcribed.

Interview on 3/1/18 with CNO, ID # 52 reported that it is the policy that all orders received are to be timed, dated, signed legibly. I do see that they wrote noted, but that is not the policy. It is not acceptable.

Record review of policy titled: General Documentation Guidelines, dated 06/2017 reads:
7. ALL clinical entries in the patient's medical record shall be aacurately dated, timed and authenticated and their authors identified.
a. Per CMS 482.24 (c) (1) - All patient medical record entries must be legible, complete, dated timed and authenticated in written or electric form by person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.