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Based on document review and interview the facility failed to ensure Patients' Rights were protected. 3 of 3 patients reviewed filed grievances and the facility did not follow the Grievance Policy and provide a quick acknowledgement, provide follow-up on the patient's behalf and/or act on the finding of the follow up investigation.
A review of the document titled Event Occurrence Executive Summary revealed the date of Event was10/4/2014, time of Event: 8:00:00 AM. The Event was rated as "Minor" by staff #8. The Event was closed on 11/3/2014. The Event was documented as follows:
"PATIENT CALLED TODAY 10/20/14 STATING THAT THE NURSE PUT AN IV INTO HER HAND AND IT HURT HER. SHE TOLD THEM IT HURT BUT THE MALE CHARGE NURSE SAID TO GO AHEAD AND USE IT AFTER HE CHECKED IT AND IT WAS WORKING. SHE TRANSFERRED TO ST. LUKES ON 10/6/2014 AND WHEN SHE GOT THERE THEY REMOVED IT BECAUSE SHE SAID IT HURT NOW THAT SHE IS HOME IT STILL HURTS AND THE PAIN GOES TO HER THUMB AND MIDDLE OF HER HAND SHE ASKED ME IF SHE SHOULD COME IN TO HAVE HER HAND LOOKED AT. I EXPLAINED THAT THE NURSES COULD NOT SEE HER UNLESS SHE WAS A PATIENT. SHE WOULD NEED TO COME TO THE ED OR GO TO HER FAMILY DOCTOR TO HAVE IT SEEN. SHE SAID OK."

This original document was altered by the facility on 6/4/2015 at 09:14 AM prior to submitting it to the surveyor. The document revealed: Note: Proprietary & Confidential Data Current as of 6/4/2015 09:14.
A review of the document titled Grievance Procedure revealed Patient Grievance: A patient grievance is a formal, written or verbal grievance that is filed by a patient or the patient's representative regarding the patient's care (when the issue is not resolved at the time of the complaint by the staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation (COP's) or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
Guidelines:
13. Guest Services and/or Administrative designee will ensure that a verbal and/or written acknowledgement of the grievance is sent to the appropriate party within seven (7) business days of receipt.
14. When the investigation is completed, a written response containing the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of the completion and the name and phone number of a contact person and will be sent to the complainant within thirty (30) days.

An interview on 6/4/2015 at approximately 10:30AM with staff #2 revealed there was no further action taken on behalf of the patient #1 by the facility at the time the grievance was filed. The original grievance was closed on 11/3/2014. There were no letters sent to the patient.
A review of the document titled Patient Relations Worksheet revealed the complaint was received by the facility on 3/18/2015. The complaint was filed on behalf of patient#2 by his wife. The complaint was as follows, "Patient passed out at home. Wife brought patient to ER. Patient has a monitor under skin that records heart. Patient states physician #11 was rude and disrespectful to him and slammed the door in his face. Did not want to hear what patient was saying."
The document revealed an entry on 4/28/2015 at 03:13 PM by Staff #2
After review of closed complaint, several issues were identified as of 4/28/2015:
1. This event was not forwarded to physician #10 as charted. Risk thought ED Director sent to physician #10 and vice versa.
2. It is discovered that actually the patient did not complain, a family member did.
3. A resolution letter was sent to the patient by Guest Services on 4/14/15.
4. Guest Services, ED Director and Risk met and discussed how confusion happened with this event. This event is now closed and records will not be sent to physician #10.

A review of the above mentioned resolution letter dated April 14,2015 and addressed to patient #2 revealed "It has been brought to my attention that your family member expressed concerns regarding the care you received in our Emergency Department here at Facility #1. I wanted to let you know that we shared these concerns with the Regional Medical Director.
We strive not only to provide a high standard of care for our patients at Facility #1, but a standard of care that is courteous, prompt and compassionate. With this said, we appreciate you taking the time to forward your concerns so we could have the opportunity to address the issues and take appropriate action.
We understand the concerns are regarding the behavior by the physician during your Emergency Room visit. We take every concern reported very seriously and these concerns have been forwarded and addressed by the appropriate department leaders. We would like to apologize that your perception of your care was less than favorable. Again, thank you for sharing your concerns regarding our hospital with our Guest Services Department ...."

A review of the document titled Grievance Procedure revealed Patient Grievance: A patient grievance is a formal, written or verbal grievance that is filed by a patient or the patient's representative regarding the patient's care (when the issue is not resolved at the time of the complaint by the staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation (COP's) or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
Guidelines:
5. Grievances and Complaints can include the following:
d. Whenever the patient or patient's representative requests that his/her complaint is handled as a formal complaint, or when the patient or patient's representative requests a response from the hospital, the complaint is considered a grievance. All grievances should be promptly forwarded to Guest Services and/or administrative designee and should be documented in the Variance reporting system. Grievances against a clinician with clinical privileges that involve allegations of care or conduct that would be detrimental to the patient's safety will be referred immediately to the Vice President of Medical Affairs and/or Regional Chief Medical Officer, in addition to Quality Management.
13. Guest Services and/or Administrative designee will ensure that a verbal and/or written acknowledgement of the grievance is sent to the appropriate party within seven (7) business days of receipt.
14. When the investigation is completed, a written response containing the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of the completion and the name and phone number of a contact person and will be sent to the complainant within thirty (30) days.

An interview on 6/4/2015 at approximately 10:30AM with staff #2 revealed there was no action taken on behalf of the patient #2 by the facility at the time the grievance was filed. The facility did not send the patient of his representative a letter of acknowledgement of the grievance with in the required seven days. The interview confirmed the letter sent to the patient on April 14, 2015 had falsely represented actions taken by the facility. Staff #2 revealed physician #11 had turned in a letter of resignation and the decision was made by physician #10 to not discipline because "the problem was go away on." The interview confirmed physician #11 had multiple patient complaints against him. The interview confirmed the allegations of care and conduct that could have been detrimental to the patient ' s safety had not been referred to the Vice President of Medical Affairs and/or Regional Chief Medical Officer.
An interview on 6/5/2015 with the Regional Chief Medical Officer confirmed patient #2's grievance had not been referred to the Vice President of Medical Affairs and/or Regional Chief Medical Officer. The Regional Chief Medical Officer repeatedly stated this is not the kind of complaint that would be referred to him. The Regional Chief Medical Officer insisted the action to take would be to refer the complaint to the Regional Director of the contracted emergency physicians group. The Regional Chief Medical Officer confirmed the fore mentioned Regional Director was contracted and worked for the emergency physicians group. The evidence provide revealed the Regional Director (physician #10) had knowledge of the complaint and chose to not discipline or counsel physician #11.
A review of the document titled "Patient Relations Worksheet" revealed a complaint was received on behalf of patient#3 by her son-in-law on 4/27/2015. The complaint was as follows: Family member (son-in-law of patient #3), was displeased because his mother in law was passing in and out of consciousness. Family thought doctor should have kept the patient, but patient was discharged. Family took her to Facility #4.

Further review of the document revealed an entry on 4/27/2015 01:47 PM by staff #3:"7 day letter sent". The document also contained the following comments on 4/29/2015 09:56 AM by staff #13:

"Patient presented to the ED with syncopal episodes and vag (vaginal) bleeding. Son-in-law stated her blood pressure was high and she was in and out of consciousness. Blood pressure on triage was 109/62, pulse 128, respirations, 20 and pulse ox 100% room air. Pain scale was 0. Glasgow was 15. IV was placed with a 500 ml bolus given. Blood work performed with H&H at 14.4 and 42.7, PT/INR normal, EKG performed. Vital signs throughout her stay was 112/72, 109, 22 and on discharge was 118/72, 98, and 20. Sent for Head CT, chest x-ray, Cervical Spine CT, Pelvis/Transvaginal US which showed a moderate-sized vaginal cuff hematoma. Was discharged with URI, Syncope and Vaginal bleeding. Instructed to follow up in the clinic on Monday and antibiotic given for the URI. Patient was alert and appropriate on discharge. Will forward this complaint to Physician #11 to investigate patient care issue".

4/29/2015 10:43 AM by staff #14:
"Son-in-law of patient #3 stated his mother-in-law was in and out of consciousness and having heavy vaginal bleeding. States her blood pressure was low. Son-in-law of patient #3 stated he was going to call a lawyer because we didn't take care of his mother-in-law and shouldn't have sent her home. States they are on their way to Facility #4 in Beaumont because she keeps going in and out of consciousness."

5/18/2015 09:13 AM by staff #3:
"Physician #11 reviewed care given ... see attached. 30 day Letter sent to patient #3".

A review of the document prepared by physician #11 and mentioned in the above entry as "see attached" revealed Patient #3 chart reviewed 5/1/15 and 5/8/2015with the following findings:
1. No vaginal exam done therefore no evaluation of ongoing blood loss.
2. Was a report of potential for vaginal injury.
3. Lab and ultrasound were done. No anemia. Ultrasound showed vaginal cuff hematoma.
Impression: Thorough ED evaluation with the exception of lack of vaginal examination.

A review of the document titled Grievance Procedure revealed Patient Grievance: A patient grievance is a formal, written or verbal grievance that is filed by a patient or the patient's representative regarding the patient's care (when the issue is not resolved at the time of the complaint by the staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation (COP's) or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
Guidelines:
5. Grievances and Complaints can include the following:
d. Whenever the patient or patient's representative requests that his/her complaint is handled as a formal complaint, or when the patient or patient's representative requests a response from the hospital, the complaint is considered a grievance. All grievances should be promptly forwarded to Guest Services and/or administrative designee and should be documented in the Variance reporting system. Grievances against a clinician with clinical privileges that involve allegations of care or conduct that would be detrimental to the patient's safety will be referred immediately to the Vice President of Medical Affairs and/or Regional Chief Medical Officer, in addition to Quality Management.

An interview was conducted with staff #2 on 6/4/2015 at approximately 11:00AM. The interview revealed physician #11 had reviewed patient #3's medical record and the care given. Physician #11's review was placed with the grievance packet and no other action was taken by the facility. Staff #2 confirmed there was no evidence the physician providing care to patient #3 received education, discipline, counseling.

An interview on 6/5/2015 with the Regional Chief Medical Officer confirmed patient #3's grievance had not been referred to the Vice President of Medical Affairs and/or Regional Chief Medical Officer. The Regional Chief Medical Officer repeatedly stated this is not the kind of complaint that would be referred to him. The Regional Chief Medical Officer insisted the action to take would be to refer the complaint to the Regional Director (physician #10) of the contracted emergency physicians group. The Regional Chief Medical Officer confirmed the fore mentioned Regional Director was contracted and worked for the emergency physicians group.