HospitalInspections.org

Based on policy review, document review and interview, the hospital failed to ensure staff followed the approved patient complaint and grievance policy for 1 of 1 (Patient #2) sampled patients reviewed for grievances.

The findings included:

1. Review of the hospital policy " Patient and Customer Complaint or Grievance" revealed, "...Patient Grievances- Actions to be taken...1. Staff will document all communications with the patient and/or patient's representative. The staff documentation will included the date, time, and as summary of the conversation...3. A written communication must be sent to the patient (or patient's legal representative), even if other methods of communication are used (such as family meeting)....In it's resolution of the grievance the hospital must provide the patient: Findings and determination regarding the grievance in a language and manner the patient and/or family understands, written notice of its decision and the name of the hospital contact person, the steps taken on behalf of the patients' to investigate the grievance, the results of the grievance process and the date of completion, a statement that provides the patient/family with information on how to contact the hospital CEO [Chief Executive Officer] or designated contact for any issues they feel remain unresolved...7. All grievances must be recorded on the hospital grievance log..."

2. Review of the facility grievance log revealed no entry for Patient #2 who was admitted to the rehab hospital on 8/29/18 with a primary diagnosis of femur fracture.

3. During a confidential telephone interview on 10/16/18 at 9:30 AM, a representative for Patient #2 reported they had voiced complaints to the Marketing Director during a meeting in the Marketing Director's office. The family representative stated the Marketing Director took notes and showed concern for their complaints.

During an interview in the conference room on 10/16/18 at 9:55 AM, the Marketing Director stated she had been made aware of a complaint form Patient #2's spouse and daughter. She stated when the family arrived to pick up his personal items after he had been transferred to an acute care hospital, they were upset that his personal items were not in the room. She stated the family was incorrectly informed by staff when he was transferred, that they could leave the items in the room for 3 days. She stated she assisted the family in looking for his items in the storage area. She stated she was familiar with the family because she had assisted with his admission. She stated the family was unable to find the patient information packet given to them at admission and she offered to get them another copy. She stated the wife began to report instances of improper care and she suggested they come to her office so they could further discuss any concerns. She stated she took notes from the meeting and made the CEO and Human Resource Director aware. She stated she did not document the complaint on the facility grievance log or inform the Quality Director about the complaint. She stated the family complained about a CNA who refused to assist the patient to the bathroom as well as a nurse who cared for him.

During an interview in the conference room on 10/16/18 at 10:05 AM the Chief Nursing Officer (CNO) stated she and Registered Nurse (RN) #1 went to the acute care hospital to meet with Patient #2's family, after she was made aware of the complaint. When asked what date she met with the family she stated she thought it was 10/5/18 but she was uncertain. She stated the family was unable to provide a name of the CNA who refused to assist Patient #2. She stated she and RN #1 pulled the schedule and determined CNA #1 might have been the employee the family was referring to. She stated they met with CNA #1 and she denied the allegations. She stated based on previous verbal warnings and her attitude, CNA #1 was placed on a written performance plan. She stated their investigation did not substantiate abuse. The CNO was unable to provide any documentation of her meeting with the family. The CNO verified she did not inform the Quality Director of the grievance so that it could be documented in the grievance log.

During an interview in the conference room on 10/16/18 at 10:00 AM, the Quality Director verified she maintained the grievance log, she further stated she was unaware of the grievance from Patient #2's family prior to the surveyors visit. She stated, "I rely on staff telling me [when they are aware of a formal grievance]."

The hospital failed to ensure all staff were knowledgeable of the policy regarding complaints and grievances, failed to ensure all grievances were maintained on the log and failed to provide a written follow up with Patient #2's family regarding their investigation and the resolution of the grievance.

Based on medical record review and interview, the nursing staff failed to document care as ordered by the physican for 1 of 4 (Patient #4) sampled patients.

The findings included:

1. Medical record review for Patient #4 revealed he was admitted to the rehabilitation hospital on 10/1/18 with gait and activities of daily living impairments secondary to a motor vehicle crash and cervical fusion.

A physician order dated 10/1/18 revealed Bladder scans every 4 hours for 2 days to determine urine volume in his bladder and perform intermittent catheter if the residual volume was greater than 300 milliliters.

Review of the nursing documentation revealed a bladder scan was performed on 10/2/18 at 5:10 PM and was not performed again until 10/3/18 at 10:06 AM. The scans were nor performed every 4 hours per physican order.

A physician order dated 10/4/18 revealed Bladder scans every 6 hours to determine urine volume in his bladder and perform intermittent catheter if the residual volume was greater than 300 cubic centimeters.

Review of the nursing documentation revealed a bladder scan was performed on 10/7/18 at 9:32 AM and was not performed again until 10/8/18 at 10:13 PM. A bladder scan was performed on 10/9/18 at 4:47 AM and not performed again until 10/10/18 at 3:15 AM. A bladder scan was performed on 10/10/18 at 10:30 PM and not performed again until 10/11/18 at 5:00 AM. A bladder scan was performed on 10/12/18 at 10:55 PM and not performed again until 10/13/18 at 3:58 PM. The scans were nor performed every 6 hours per physican order.

2. During an interview in the conference room on 10/16/18 at 1:26 PM, RN #1 verified the bladder scans had not been documented in the electronic medial record as the physican ordered them. She verified there was no way to ensure the scans were completed every 4 or 6 hours.