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Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a patient grievance resolution included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. In four grievances reviewed the above information was not in the letters to the complainants.


Findings:

1. In the review of the complainant's grievance letter to the facility dated 01/20/10, the first response letter was dated 02/12/10, the final letter was dated 03/03/10. The final response letter did not contain the steps taken to investigate the grievance, the results of the grievance process and the date of completion.

2. Three grievances reviewed did not include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

3. The policy includes all the required information. The facility did not follow their policy.

Based on a review of policies and procedures, incident reports, staffing sheets, interviews with the drug room nurse and administrative staff, the hospital failed to ensure the nurses administering patient medications followed the correct protocols for medication administration. In one of seven incident reports for medication errors, the nurse did not follow the accepted standards of practice for medication administration

Findings:

1. Patient chart #1. The physician discontinued the IV antibiotic on 11/30/09. The nurse administered another dose of the antibiotic on 12/02/09. There was no new order for this medication.

2. The Encyclopedia of Nursing & Allied Health,Fundamentals of Nursing: Concepts, Process, and Practice, 4th ed.. St Louis: Mosby-Year Book, Inc., 1997 states "Before administration, five factors often referred to as the 'five rights' should be addressed." The five rights are:
a. Right patient
b. Right drug
c. Right route
d. Right dose
e. Right time.

3. Joint Commission of Hospital Accreditation (2006_, Hospitals National patient Safety Goals and Mosby's Pocket Guide Infusion Therapy (5th ed) include two more "Rights" which are the "right reason" and the "right documentation."

4. The nurse who administrated the IV antibiotic did not adhere to the acceptable standards of practice for medication administration. She did not have the right patient, right drug, right time, right reason, and the right documentation.