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Based on interview and record review, the hospital failed to ensure a grievance was reviewed and completed timely for one of two sampled patients (Patient 1). This failure created the increased risk of a failed grievance process.

Findings:

Review of the hospital's P&P titled Grievance/Complaint Process dated 9/2022 showed if an issue is unable to be resolved on the spot, within seven days following the submission, the patient will be provided with a written notice. If a prolonged investigation is anticipated, the patient will be informed of this fact and the anticipated length of the investigation.

On 7/15/2024, a review of Patient 1's grievance was conducted.

Review of Patient 1's complaint form showed a complaint was submitted on 7/2/24 (no time) for an event on 7/1/24, of a patient care concern regarding the patient and MD 1 for unprofessionalism and harassment. Review of the document showed the complaint was referred to the Medical Director for ED.

Documentation showed the Executive Assistant forwarded the grievance by email to the Medical Director of ED on 7/2/24 at 1127 hours. On 7/12/24 at 1347 hours, the Executive Assistant sent another email to the Medical Director of ED stating Patient 1 had yet to receive any resolution actions from the hospital. On 7/12/24 at 1422 hours, the Medical Director of ED sent an email stating MD 2 called Patient 1 four times with no response.

On 7/15/2024 at 1211 hours, an interview was conducted with MD 2. MD 2 stated he was made aware via email of Patient 1's grievance on 7/2/24. MD 2 stated however, the attempts to call Patient 1 did not occur until 7/12/24.

On 7/15/2024 at 1330 hours, the above findings for the grievance to not be reviewed and completed timely were shared and acknowledged by the CMO, CNO, and Director of Performance Improvement.

Based on interview and record review, the hospital failed to provide a written notice of the resolution of the grievance as per the hospital's P&P for one of two sampled patients (Patient 1). This failure had the potential to result in the increased risk of a failed grievance process.

Findings:

Review of the hospital's P&P titled Grievance/Complaint Process dated 9/2022 showed a patient concern is defined as an expression of displeasure or dissatisfaction with service received. A resolution is achieved at the time of the concern by the staff. A patient grievance is a written or verbal concern by a patient regarding care, abuse, or neglect. The Grievance Committee will assure the grievance is investigated timely. If an issue is unable to be resolved on the spot within seven days following the submission, the patient will be provided with a written notice of:

- The name and number of the hospital contact person should further information be required.

- The steps taken on behalf of the patient to investigate the grievance.

- The results of the grievance process.

- The date of the investigation was completed.

On 7/15/24 at 1040 hours, an interview and concurrent review of Patient 1's grievance was conducted with the CNO.

Review of Patient 1's complaint form showed a complaint was submitted on 7/2/24 (no time) for an event on 7/1/24, of a patient care concern regarding the patient and MD 1 for unprofessionalism and harassment.

However, further review of hospital records failed to show a written notice of the grievance was sent to Patient 1 according to the hospital's P&P. When asked, the CNO stated the CNO was part of the grievance committee. The CNO stated the hospital treated Patient 1's care issue as an ongoing concern which initially started as a complaint. However, the CNO stated the issue was not resolved and acknowledged the grievance process was not implemented according to the hospital's P&P.

Based on interview and record review, the hospital failed to ensure one of two sampled patients (Patient 1) was informed of the AMA discharge as per the hospital's P&P. This failure had the potential for the patient to not be allowed to make medical care decisions.

Findings:

Review of the Medical Staff General Rules dated 12/2018 showed should a patient leave the hospital against the advice of the attending physician, every effort will be made to have the patient sign the hospital AMA form. The patient will be informed of the risks of leaving the hospital AMA.

Review of the hospital's P&P titled Discharge of Patients Against Medical Advice dated 9/2022 showed the patient's physician should attempt to provide the patient with information as to why the continued treatment is recommended and the potential consequences of the action so the patient can make an informed decision on whether to leave the hospital. The patient's signature (or refusal to sign) must be witnessed by a hospital employee.

Review of the hospital's P&P tiled Aftercare Instructions dated 9/2022 showed each patient who is discharged from the ED will receive a written After Care Instruction form. The ED MD will generate a computer set of instructions specific to the patient's diagnosis including what treatment was provided and what follow-up care is needed. The After Care Instruction form must be verbally explained to the patient and a signature from the patient obtained. A copy of the After Care Instruction form will be given to the patient and the original signature sheet must be returned to the medical records department staff to be scanned into the patient's EMR.

On 7/15/24, Patient 1's medical record review was initiated. Patient 1 visited the ED on 7/1/24, with a complaint of back pain.

Review of the ED Provider Notes dated 7/1/24 at 1226 hours, showed MD 1 provided an MSE for Patient 1 regarding back pain. The section to determine the medical decision showed the severity of Patient 1's back pain was mild, and Patient 1 was discharged AMA. However, further review of the patient's medical record failed to show MD 1 had discussed the risks and benefits of leaving AMA with Patient 1.

Review of Patient 1's medical record failed to show evidence of the completed AMA form.

Additionally, review of the After Visit Summary form dated 7/1/24, showed no documented evidence Patient 1 had signed and acknowledged receiving the discharge instructions and advisements to return to the ED for worsening symptoms. The After Visit Summary form failed to include the specific details related to Patient 1's chief complaint of back pain.

On 7/15/24 at 1330 hours, the CMO, CNO, and Director of Performance Improvement were informed and acknowledged the above findings.