HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility failed to ensure the written response letter to the patient provided adequate information to address appropriate and reasonable actions taken on the patient's behalf to resolve their grievance. 4 of 4 patient grievance letters did not include the appropriate and reasonable actions taken to resolve the patient's grievance.

The findings include:

Review of patient medical records, on 3/4/14 from 10:30 a.m. to 11:45 a.m., revealed grievance letters sent to patient #2, 3, 4, and 5 did not provide adequate information to address the actions taken in regard to specific grievance of the patients. Each letter states the patient grievance then has the following statement "We have fully investigated these issues, met with the Chief Nursing Officer and other members of the Leadership team and took action to address your complaints. We believe we have taken appropriate corrective measures to prevent these issues from occurring again and apologize for any inconvenience this caused."

Review of facility policy titled "Patient Complaint/Grievance Process" states, in part "The Hospital CEO/Administrator or designee completes Step 4 of the form: Reviews the findings and actions documented in Steps 1 through 3 and documents additional actions taken. Sends a written response to the complainant within 7 days. The letter shall include: steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the dates of completion."

In an interview with the Chief Nursing Officer(CNO) on 3/4/14 at 4:30 p.m. she acknowledged the letters to the patient did not provide adequate information to include measures taken to address the patient grievance other than to meet with the CNO and leadership team. She further acknowledged 2 complaints in November in regard to rudeness of staff even though the letters to the patients in October stated the hospital had taken appropriate actions to ensure these issues did not occur again.

Based on incident report review, policy review, and staff interview the facility failed to analyze all adverse patient events for cause and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

The findings include:

Review of incident report for patient #1 filled out on 1/11/14 for an event of an AMA (against medical advice) that occurred on 1/9/14 revealed there was no investigation completed for contributing factors or prevention of the incident.
The incident report states the following:
* Detailed description of what occurred: Pt family unhappy and wants to transfer patient to BSA. Daughter c/o no stand-up lift and uncontrolled pain and wants patient to be evaluated to be readmitted to BSA.
* Immediate actions: blank
Signed by RN on 1/11/14 at 0900
* Section to be completed by Supervisor or Department Head-Document steps that have been taken to prevent reoccurrence: Pt/family unwilling to comply with therapy, etc. Many attempts made to educate without success. Family informed that the hospital would not provide transportation for AMA. They called ambulance themselves. Ambulance/EMTs informed this was not a transfer and not the responsibility of the hospital.
* Contributing Factors: blank
* Prevention: blank
Signed by Chief Nursing Officer on 1/10/14- no time documented
* Section titled Outcome: Has check on Level 3-Moderate Outcome. Moderate, temporarily adverse outcome requiring treatment ordered by a physician or emergency room evaluation. (Report to CEO and VP of Quality)
* This section to be completed by Quality/Risk Management Department-Describe any follow-up activities or actions taken: Blank
* CEO notified: Yes; signed by CEO on 1/10/14 at 0900

Facility policy titled "Incident Reporting" states "An incident is defined as an unusual event involving a patient, visitor, or employee, which may transpire in or on the premises of the facility ...." "Incidents to be reported include but are not limited to those related to: AMA." "Investigation- The investigation process is coordinated through Quality Management with those areas impacted by the incident. The initial investigation occurs within 24 hours of the receipt of report .....The goal is to complete a comprehensive analysis of the event within 45 days."

In an interview with the Chief Nursing Officer on 3/4/14 at 3:20 p.m. she stated she did not do any further investigation and did not complete the form as to contributing factors and prevention of the occurrence. She further stated the Director of Quality Management(DQM) left on 12/31/13 and they have coverage from a sister facility. She stated the covering DQM has been out sick off and on and has not been at the facility or reviewed this adverse event per the facility policy.

Based on medical record review and staff interview the facility failed to provide services ordered by the physician.

The findings include:

Record of medical record for patient #1 on 3/4/14 at 9:30 a.m. revealed the physician had written an order for a trapeze bar for assistance with repositioning on 1/2/14.

Interview with staff #3, 4, 5, & 6 on 3/4/14 revealed the trapeze bar was never placed on the patient bed as per physician orders. Staff #3 stated he did not like for patients to use them as they were not available for patients to use when they went home and the reason for their stay at the hospital was to transition patients to home care.