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Based on hospital policy review, grievance file review, staff interview, medical record reviews, Emergency Medical Services (EMS) Patient Care Report (PCR), EMS staff interview, physician interview, DED physician staffing schedule, and review of Hospital B's medical record, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the hospital met the emergent needs of patients and have the hospital wide nursing services under the direction of one Registered Nurse (RN).

The findings include:

1. The Hospital (Hospital A) failed to meet the emergency needs of patients in accordance with acceptable standards of practice.

~cross refer to 482.55 Emergency Services Condition: Tag A1100.

2. The hospital failed to have one nursing service hospital-wide under the direction of one Registered Nurse (RN).

~cross refer to 482.23 Nursing Services Condition: Tag A0385.

Based on policy and procedure review, Grievance file review and staff interview the staff failed to include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in the written notice of the resolution of the grievance in 2 of 3 Grievance files reviewed (#10, #2).

The findings include:

Review of the facility policy 8325-O.H entitled " Complaints & Grievances (Patient)" revised 8/2010 revealed upon receipt "of the grievance in the Risk Management Office, the grievance shall be entered into the computerized tracking system. 2. Within 7 business days a letter will be sent to the patient/patient representative from the Risk Management Office that outlines the following: a. the steps that have or will be taken on behalf of the patient to investigate the grievance, b. the results of the process or an explanation that the review is ongoing and that an additional response will be forthcoming. c. the date of the completion or the expected date of completion d. and the person to contact regarding the grievance process". Further review revealed upon being notified of the resolution of the grievance, "the Risk Management Office shall send correspondence to the patient/patient representative to inform the patient of the resolution of the grievance. The correspondence will outline: a. the steps taken on behalf of the patient to investigate the grievance, b. the results of the process, c. the date of completion, d. and the person to contact regarding the grievance process".

1. Grievance file review for patient #10 revealed the mother was the complainant. Review of the Grievance report form dated 03/27/2013 revealed the mother made a verbal grievance to the Emergency Department (ED) Administrative staff on 03/27/2013 regarding the care her child had received while in the ED and the staff not notifying her when the hospital transferred her child to another Hospital. File review revealed written documentation dated 04/04/2013 sent to the complainant. Review of the written documentation did not reveal any documentation of the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion. Interview with administrative compliance staff on 08/28/2013 at approximately 1500 revealed this "letter" is the only documentation that was sent to the complainant. The interview revealed the staff thought the letter contained all information per the facility policy.

2. Grievance file review for patient #2 revealed the patient and spouse were the complainants. Review of the Grievance report form dated 06/11/2013 revealed the patient and spouse made a verbal grievance to the Emergency Department (ED) Administrative staff on 06/11/2013 regarding " 'how the doctor had not been in to see the patient' and ...'they wanted to see a doctor. That's was what they were here for' ". File review revealed written documentation dated 06/20/2013 sent to the complainant. Review of the written documentation did no reveal any documentation of the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion. Interview with administrative compliance staff on 08/28/2013 at approximately 1500 revealed this "letter" is the only documentation that was sent to the complainant. The interview revealed the staff thought the letter contained all information per the facility policy.

Based on policy and procedure reviews, grievance file review, administrative staff interview and facility documentation review, the Emergency Department (ED) medical staff failed to ensure a well organized ED medical staff by failing to have a consistent process per the facility's policies for the assessment and evaluation of patient grievances regarding ED physicians services.

The findings include:

Review of facility policy 6010.3.11.H revised 05/2011 titled Conflicts Involving Care revealed "If any care giver has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, she/he shall call this to the attention of the supervisor who may direct this matter through the nursing chain of command. If warranted, nursing supervisory personnel shall bring the matter to the attention of the attending physician, hospital administrator, chief of service of the attending or chief of staff as appropriate. The chief of staff may himself request a consultation".

Review of facility policy 8325.-.O.H. revised 08/2010 titled Complaints and Grievances (patient) revealed "5. Grievances involving physician services will be addressed under policy entitled "Patient Complaints and Grievances Involving Physicians".

Review of facility policy 8325.-.O.H. reviewed 03/2013 titled Patient Complaints and Grievances-Medical Staff revealed "To protect and promote each patient's rights by establishing a process for prompt resolution of patient complaints and grievances that involve a member of the (Name of Hospital) Medical Staff...Grievance Procedure:...2. Within 7 business days the Chief Executive Officer or designee will send a letter to the patient/patient representative...3. The Chief Executive Officer or designee shall send notification of the grievance to the physician and to the appropriate Chief of Service. The notification will be provided via email or through memo. The Chief of service or designee will review the grievance to determine if there is a quality of care concern, Quality of Care issues will be referred to the medical Staff QA Committee

Grievance file review for patient #2 revealed the patient and spouse were the complainants. Review of the Grievance report form dated 06/11/2013 revealed the patient and spouse made a verbal grievance to the Emergency Department (ED) Administrative staff on 06/11/2013 regarding " 'how the doctor had not been in to see the patient' and ...'they wanted to see a doctor. That's was what they were here for' ". File review revealed the named physician in the grievance was the Emergency Department Medical Director. File review revealed electronic mail (e-mail) dated 06/13/2013 at 1136 from Facility administrative staff to Physician #1 (Emergency Department Medical Director) as an informational communication. File review revealed e-mail documentation from Physician #1 dated 06/13/2013 at 1221 to Physician #2 to review the attached chart and render an opinion on the "care, complaints". File review revealed e-mail response from physician #2 dated 06/20/2013 at 0401 back to physician #1 regarding the review of two complaints dated 06/11/2013. File review revealed e-mail from physician #1 forwarding physician #2's response sent to Facility administrative staff on 06/20/2013 at 0959. File review revealed e-mail from Facility administrative staff dated 06/20/2013 at 1002 forwarding e-mails to Compliance administrative staff. File review revealed written documentation dated 06/20/2013 sent to the complainant. Review of the written documentation did no reveal any documentation of the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion. Interview with administrative compliance staff on 08/28/2013 at approximately 1500 revealed this "letter" is the only documentation that was sent to the complainant. The interview revealed the staff thought the letter contained all information per the facility policy. The interview revealed physician #2 was supervised by physician #1.

Interview on 08/28/2013 at 1145 with the Manager of the Medical Staff Services and Compliance administrative staff revealed the process for review of patient grievances regarding a physician is the grievance is sent to the Service Line Medical Chair from the Compliance department. Each Service line has a Chair and Vice Chair. The interview revealed the hospital has two separate contracted physician groups providing services, one group for the ED on campus and one for an ED off campus. The ED is under the Hospital Services line. The Chair may delegate the review of a grievance to the Vice Chair. The interview revealed the Vice Chair for the Hospital service line is the ED Medical Director. The interview revealed the Vice Chair may designate one of the Staff ED physicians to review the grievance. The staff ED physician will give recommendations/findings back to the Vice Chair to report to the Service line Chair. The interview revealed for Grievance File patient #2, the Vice Chair delegated review of the grievance to ED staff physician #1 since the grievance was regarding the ED Medical Director. The findings were given back to the ED Medical Director (Vice Chair) to go back to the Chair of Hospital Services.

Interview with the ED administrative staff at the the off campus ED site on 08/28/2013 at 1240 revealed the process for the assessment and evaluation of a grievance regarding the ED physician services would begin with the ED Medical Director at the off site campus, Physician C. The interview revealed if the grievance was about physician C (the ED Medical Director) the grievance would go the the Medial Director of the physician contract group for review.

Based on administrative staff interview the hospital failed to have an organized nursing.

The findings include:

1. The hospital failed to have one nursing service hospital-wide under the direction of one RN.

~cross refer to 482.23(a) Nursing Services Condition: Tag A0386.

Based on administrative staff interview the hospital failed to have one nursing service hospital-wide under the direction of one RN.

The findings include:

Interview with administrative staff on 08/27/2013 at 0945 revealed the hospital had two Directors of Nursing (DON). The interview revealed one DON was over nursing services on the main hospital campus and another DON was over nursing services at an off site hospital campus. The interview revealed the organizational chart documented two DONs. The interview revealed nursing services reported directly to the respective DON at each campus for all aspects of the nursing services provided at each campus. The interview revealed the facility was aware there should only be one DON per accreditation standards. The interview revealed the hospital was planing to have one DON over nursing services hospital wide but had not completed this.

Based on review of policy and procedures, Emergency Medical Services (EMS) Patient Care Report (PCR), EMS staff interview, physician interview, DED physician staffing schedule, and review of Hospital B's medical record, the Hospital (Hospital A) failed to meet the emergency needs of patients in accordance with acceptable standards of practice.

The findings include:

1. The Hospital (Hospital A) failed to provide an appropriate medical screening examination and diverted an unstable individual when the hospital was not on diversionary status.

~cross refer to 482.55 Organization and Direction - Standard: Tag A1101.

Based on review of policy and procedures, Emergency Medical Services (EMS) Patient Care Report (PCR), EMS staff interview, physician interview, DED physician staffing schedule, and review of Hospital B's medical record, the Hospital (Hospital A) failed to provide an appropriate medical screening examination and diverted an unstable individual when the hospital was not on diversionary status in one of one patients diverted (#23).

The findings include:

Review of Policy "Ambulance Diversion Policy 6230.-H" revised 10/2012 revealed "(name of hospital A's main campus DED (dedicated emergency department) and off-campus DED)are the only Emergency Departments located in xxx (name of county); therefore, ambulance diversion is only implemented in extreme circumstances. PROCEDURE: The Emergency Department may temporally divert all ambulances with exception of patients with signs or symptoms of acute coronary syndrome or a life/limb threatening illness...".

Review of the EMS PCR revealed the county ambulance arrived at patient #23's home on 12/19/2013 at 0919. Review revealed at 0921 pulse oximetry (ox) was 86% (normal range > than 94%), respirations 16 shallow and Glasgow Coma Scale (rating for neurological status) was rated 5 (3-8 considered severe). At 0923 the Blood Glucose was 62 (normal 70-100) and temperature was documented at 0924 at 101.3 F (normal 98.6 F). At 0929 the patient was placed on a nonrebreather mask (type of oxygen delivery system) at 15 liters per minute. Vital signs were assessed at 0930 heart rate 108 (normal 60-100), blood pressure 80/62 (120/80 normal), pulse ox 100%, respirations 16 shallow, GCS 5. Review revealed at 0945 ambulance paramedic contacted Hospital A for medical orders for 1/2 ampule of D 50 (IV solution to increase blood sugar quickly) and to withhold fluid bolus due to rales (abnormal lung sounds) present in lung. Further review revealed "approved by Dr. ZZZ (name of Hospital A's DED physician) to go ahead with D 50 and withhold fluid unless B/P went below 70 systolic". At 0949 a reassessment was completed, heart rate 118, B/P 86/42, pulse ox 100%, respirations 14 and shallow. Review revealed at 0956 "contacted Hospital A via cell phone, per Nurse #1 (name of DED nurse). Dr. ZZZ states for the patient to be diverted to the facility she had surgery at. Advised Dr. ZZZ of patient's unstable condition and was told 'take the patient somewhere else' said nurse #1". Review revealed at 1007 reassessment was completed; heart rate 111, B/P 70/41, pulse ox 100%, respirations 14 and shallow. Review revealed at 1012, patient reassessed and vital signs were: heart rate 112, B/P 68/38, respirations and GCS unchanged. Further review at this time revealed "contacted Hospital A ER. Dr. ZZZ to request a Dopamine drip due to the patient's declining blood pressure and lung sounds of rales in the distal lobes. Per Dr. ZZZ bolus the patient normal saline 500cc. Orders for Dopamine denied at the present time." Review revealed that patient arrived at Hospital B at 1029.

Interview with administrative EMS staff on 08/29/2013 at 1000 revealed the county owned the ambulance service and owned the hospital. Interview revealed that Hospital A is the only hospital in the county. The interview revealed the county ambulance service is prohibited from transporting emergency patients outside of the county line unless the patient request out of county transport or patient is a trauma. The interview revealed even with patient request, due to the severity of the condition of the patient, the patient would not be transported outside of county lines and would be transported to Hospital A. The interview revealed that EMS administrative staff were aware of an unstable patient enroute to Hospital A that was diverted outside of the county to Hospital B.

Interview with Dr. ZZZ (name of DED medical director) on 08/29/2013 at 1420 revealed he did not remember any incident of a patient being diverted enroute to Hospital A. After Dr. ZZZ reviewed the EMS PCR form for patient #23 revealed Dr. ZZZ did not "recall" the diversion of patient #23. The interview revealed the patient may have asked or requested to go to Hospital B. Interview revealed that even with request if the patient is unstable, the patient must come to the nearest hospital available, Hospital A. The interview revealed that Dr. ZZZ was unsure if he was on duty 12/19/2012. Interview revealed that had he been told the patient was unstable he would have requested the patient come to Hospital A.

Review of the DED physician staff schedule for 12/19/2012 revealed Dr. ZZZ was on duty in the DED from 0700 to 1700. Review of the schedule revealed that Dr. ZZZ was the only physician available on duty until 1400.

Review of medical record for patient #23 revealed the patient arrived via EMS to Hospital B at 1029. Review of the emergency physician's MSE revealed the patient "does appear to be in significant distress." Review reveal the patient was admitted into the ICU (intensive care unit) with a diagnosis of AMS (altered mental status). Medical record review revealed the patient expired 12/29/2012.

NC00091265