HospitalInspections.org

Based on policy review, document review and interview, the facility did not provide Patient A with a timely, written response to their grievance in accordance with facility policy.

Findings Include:

Review of policy 422.1 " Patient Complaint of Service " effective 2/18/15 revealed if a complaint cannot be resolved at the time of the complaint, is referred to other staff for resolution, requires investigation, then it is considered a grievance. Within 7 days of receipt of the grievance, the Patient Advocate will send the patient a written response or inform the patient the hospital is working to resolve the grievance and may expect a written response not to exceed 30 days.

Review of the Dialysis meeting minutes dated 6/10/15 at 1:00pm revealed on 6/8/15 there was a water penetration at the commode in ICU room 14 into room 9 on 7 East. The patients in room 9 on 7 East were moved to another floor.

Review of the Complaint Log dated 6/30/15 revealed a complaint was received from Patient A stating that water from a dialysis machine on the floor above leaked through the floor and dripped on her. The patient requested a copy of the incident report. It was noted that the nurse manager would call the patient.

Review of the Quantros Incident reports dated 7/13/15 at 2:36pm and 8/16/15 at 9:26am revealed the patient is upset regarding the leak. The patient requested a copy of the incident report, but never got it.

Interview on 9/18/15 at 2:27pm with Staff # 7, revealed the facility did not provide a written response to the patient regarding the complaint investigation and findings.

Based on observation and interview the facility does not maintain all components of the fire alarm system.

Findings include:

During the facility tour on 08/19/15 it was observed that the audio/visual (AV) device near room H2-261 had a constant buzzing noise emanating from the speaker. Two other AV devices in the suite had a similar noise emanating from the speaker.

Interview with Staff #5 on 08/19/15 revealed that it could be a ground-fault and that Simplex-Grinnell would be contacted immediately.

Based on observation and interview the facility does not maintain all components of the vacuum system (medical gas).

Findings include:

During the facility tour on 08/19/15, it was revealed that the analog gauge, for the vacuum system, in the zone valve shutoff box outside of room 905 Fluoroscopy Room, in the endoscopy suite, indicated a pressure if 8 inches of mercury (in.Hg). The local alarm panel, for the endoscopy suite, indicated that the pressure for the vacuum system had a pressure of 16 in.Hg.
If the pressure drops below 12 in.Hg the low level alarm for vacuum should activate. No alarm was indicated.

Interview with Staff #5 on 08/19/15 revealed the gauge was bad and that it would be replaced.