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Based on record review and staff interview, it was determined the hospital failed to establish and follow a process to fully investigate patient grievances. This was found for one of three patient grievances submitted for the hospital emergency department for the month of August, 2013. (Patient #1)

A review of a patient grievance for Patient #1 revealed this grievance was submitted on 8/15/13. The grievance alleged that extended time intervals between episodes of patient care occurred from the time of the patient's arrival on 08/03/13 to the patient's death on 08/04/13. The grievance also alleged the staff neglected to secure an intravenous line in the patient's neck that caused it to be inadvertently removed.

An interview was conducted on 10/11/13 with one of the registered nurses responsible for Patient #1's care on 08/03/13. This person stated she could not remember any reason for extended lapses in the patient's care or if any of these lapses even occurred. This person did remember that an intravenous line had been inserted in the patient's jugular vein. However, the patient had been sent to the radiology department and the intravenous line was not present upon the patient's return.

Interviews were not conducted with the emergency department physician and one of the primary nurses responsible for the care of Patient #1 and these persons were no longer on staff with the hospital and were not available for interviews at the time of the survey.

A review of the hospital's investigation regarding this grievance revealed the medical record timeline was reviewed by the risk manager. However, it could not be determined any other steps were taken to validate or disprove the complainant's allegations. Interviews with the patient advocate and risk manager on 10/14/13 revealed no staff persons who had provided care for Patient #1 had been interviewed concerning these grievances. A copy of a letter dated 10/03/13 that was sent to the complainant was reviewed. This document stated the hospital had investigated the grievance and found the care provided for Patient #1 had been "appropriate". The grievance had been closed on that date. A review of the hospital's policy titled "Complaint-Grievance Resolution" revealed this policy failed to specify any investigative procedures that would be employed in order to resolve care related grievances.