HospitalInspections.org

Based on review of documents and interview of staff it was determined the facility failed to develop a policy for patient grievances which specified the time frame for a written final response to a formal complaint. Failure to determine a reasonable time in which to investigate and attempt resolution of a complaint infringes on the rights of all patients.

Findings include:

1. Facility policy entitled "Policy for Management of Complaints/Grievances", last revised 11/2013, was reviewed on 6/2/16.
It states: "The patient...will be informed of the complaint/grievance process and expected timeframe of the response...not to exceed 7 days".

2. A joint interview was conducted with the Vice President of Quality/Risk and the Risk Management Assistant on 6/2/16 at 11:55 a.m. at which time the current policy was reviewed. Both individuals agreed the facility expectation is for an initial response to the complainant within the stated seven (7) day time frame and a thirty (30) day time frame for the final written response. Both further agreed the thirty (30) day time frame is not specified in the current policy.


B. Based on review of documents and interview of staff it was determined the facility failed to respond to a complainant for one (1) of one (1) patient complaints reviewed per policy (Patient #1). Failure to communicate the status and result of a complaint investigation infringes the rights of all patients.

Findings include:

1. Facility policy entitled "Policy for Management of Complaints/Grievances", last revised 11/2013, was reviewed on 6/2/16.
It states: "The patient...will be informed of the complaint/grievance process and expected timeframe of the response...not to exceed 7 days. Regardless of the nature of the complaint/grievance, direct verbal communication will be maintained with the patient...during the complaint/grievance process."

2. The complaint file of Patient #1 was reviewed on 6/2/16. It revealed a letter of complaint was then received by the facility dated 5/1/16. No documentation was found to indicate any communication from the facility to the complainant had taken place since receipt of this letter.

3. A joint interview was conducted with the Vice President of Quality/Risk and the Risk Management Assistant on 6/2/16 at 11:55 a.m. at which time the above documents were reviewed. Both agreed there had been no communication with the complainant since receipt of the letter dated 5/1/16 and both agreed this did not conform to facility policy or expectation for the time frame of response to a grievance.

Based on document review and staff interview it was determined the facility failed to ensure monitoring of vital signs every thirty (30) minutes during blood transfusions, per policy, for three (3) of four (4) patients receiving blood (Patients #4, #5, and #8). Failure to correctly monitor the effects of blood transfusions on patients can lead to undetected and untreated adverse reactions with possible negative outcomes.

Findings include:

1. Facility policy entitled "Protocol on management of a patient requiring a blood transfusion", last revised 9/11, last reviewed 12/14, states under the heading "Assessment/Interventions: 6. Assess pulse, blood pressure, respirations every 30 minutes."

2. Patient #4's medical record was reviewed on 6/1/16. Review of the document entitled "Blood Bank History" revealed the patient received a blood transfusion on 5/24/16 from 10:20 p.m. to 5/25/16 at 1:00 a.m. Vital signs reviewed for that date and those times revealed the final two (2) vital signs were obtained thirty-five (35) and then fifty-five (55) minutes from the previous set. The patient received a transfusion on 5/25/16 from 5:00 a.m. to 7:20 a.m. and review of vital signs revealed thirty-five (35) minutes, and then sixty (60) minutes between sets. The patient received a transfusion on 5/26/16 from 12:00 a.m. to 3:00 a.m. and review of vital signs revealed the last two (2) sets to be fifty-nine (59) minutes and sixty-three (63) minutes apart.

3. Patient #5's medical record was reviewed on 6/1/16. Review of the document entitled "Blood Bank History" revealed the patient received three(3) blood transfusions during his hospital stay. Review of vital signs for all transfusions revealed all sets obtained were sixty (60) minutes apart.

4. Patient #8's medical record was reviewed on 6/1/16. Review of the document entitled "Blood Bank History" revealed the patient received a blood transfusion on 3/9/16 from 4:45 p.m. to 7:05 p.m. Review of vital signs revealed the last set obtained to be sixty (60) minutes from the previous set.

5. The above documentation was reviewed with the Nurse Manager of ICU on 6/1/16 at 12:00 p.m. at which time she agreed with these findings.