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Based on medical record review, policy review and interview, the hospital failed to investigate and/or follow up on a complaint/grievance. There was a total of 10 medical record reviews. The affected one Patient (#7) of ten medical records reviewed. The patient census was 193.

Please see A0118

Based on medical record review, policy review and interview, the hospital failed to investigate and/or follow up on a grievance. This affected one (Patient #7) of ten medical records reviewed. The patient census was 193.

Findings include:

Review of the emergency department encounter note for Patient #7 revealed she arrived at the emergency department (ED) by emergency medical services (EMS) on 01/30/20 at 8:30 PM. Review of the demographic face sheet revealed there was no power of attorney (POA) documents received and that Patient #7 was responsible for herself. Patient #7 was alert and oriented. Patient #7 was walking in her kitchen, stated she tripped and fell. She complained of right arm pain aggravated by movement and posterior head pain. The patient had a history of dementia. An X-ray was completed and revealed fractures of the proximal radius and ulna and a splint was applied. There was no evidence of neurovascular injury. The clinical nurse practitioner (CNP) consulted with the house doctor. The plan was to have Patient #7 follow up on an outpatient basis. Patient #7 ambulated in the hallway without any assistance needed or gait abnormalities and went to the bathroom without any assistance. Patient #7 was offered admission to the hospital but declined and stated she wanted to go home. Patient #7 typically does live alone, does have home health care coming tomorrow according to Patient #7. The physician documented "I do believe Patient #7 is stable for discharge home. Patient #7 adequately demonstrated ability to perform her own ADL's in ED, remained afebrile and hemodynamically stable, neurovascularly and neurologically intact and therefore do believe that she is stable for discharge home." Patient #7 was instructed to follow up as an outpatient in two days and to return to ED immediately for any new or worsening symptoms. Patient #7 was given the aftercare visit summary (AVS) but was unable to sign due to a right ulnar fracture but did verbalize understanding.

The ED encounter note revealed the patient's grandchildren were visiting in the ED at one point, but left. Patient #7 stated she had no one to take her home, so a car service (LYFT) was called.

Review of a coordination of care note signed by Staff J, dated 02/02/20 at 9:13 A.M. revealed Patient #7's son, who identified himself as the durable power of attorney (DPOA) was upset because Patient #7 was sent home from the emergency department (ED) using a car service with no instructions as to what happens next. The son stated he lived in Florida, but Patient #7 had family in town that had visited. The family was told Patient #7 was to be admitted to the hospital and come to find out Patient #7 was sent home using a car service. The family is reporting they had no idea how Patient #7 got home. Staff J informed the patient's son of the discharge orders. The son was to send paperwork indicating he is the DPOA because he requested for Staff J to fax him the after visit summary (AVS) for reference. Staff J left a message for Staff E about family concerns and how the patient was discharged around midnight using a car service.

Interview with Staff E on 07/14/20 at 2:03 PM revealed Staff J reported to Staff E that Staff J talked to Patient #7's son the weekend he/she was in the ED and the patient's son was upset because he was not made aware of Patient #7's after visit summary care (AVS). Staff E further revealed that she spoke with the patient's son on 02/03/20 and he was confused as to why no one contacted him in regard to his/her AVS care and why Patient #7 was sent home so late. Staff E revealed she reported this information to Staff G for follow up care.

Interview with Staff C on 07/14/20 at 2:10 PM revealed there is no documented evidence that Staff G did a follow up and there was nothing documented on the ED complaint log.

Interview with Staff C on 07/14/20 at 3:09 PM revealed it was found out today that Staff G did not follow up with Patient #7's son and that Staff J should have entered the complaint into the Safecare system which would have gone to Staff I and Staff G in the ED department. Staff C also revealed that the grievance committee receives emails daily for any events entered into Safecare system.

Staff C further revealed that Staff J should have entered the grievance into the Safecare system.

Interview with Staff H on 07/14/20 at 3:47 PM revealed normally she is made aware of complaints and grievances. The person whom receives the complaint/grievance puts it into the Safecare system and then Staff H would work with the hospital leaders and encourages the Manager of the department in which the complaint came from to do the follow up. Staff H revealed she does not know why she was not made aware of the complaint made by Patient #7's son.

Interview with Staff G on 07/14/20 at 3:51 PM was made aware of Patient #7's son making a complaint the day after Patient #7 was in the ED. Staff E sent Staff G an email later in the day after she talked to Patient #7's son. Staff G revealed when she received the email she was on leave of absence and forwarded the email to the ED manager, Staff I, to review.

Interview with Staff I on 07/14/20 at 4:05 PM revealed that he vaguely remembers Patient #7. Staff I revealed that the complaint for Patient #7 was not entered into Safecare to follow up on so the ED manager reviewed Patient #7's medical record and did not go any further.

Review of the policy and procedure titled Patient Complaint and Grievance, approved by Mercy Health System Quality Committee, approval date: 04/02/18, next review: 04/02/20, Policy Number: none, Policy Level: System/Corporate, Revision: 7, Originating Department: Quality, Contributing Departments: Compliance, Legal, Regulatory, Risk Management, Manual: Administration Manual, Section: Quality Performance Improvement, Policy Start Date: 02/01/17 was including the purpose to assure a process that is concise, timely and consistent when responding to and resolving a patient/patient representative's complaint or grievance and to promote the opportunity to improve the delivery of care and services.

A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative regarding the patient's care; a patient or their representative calls or writes to the hospital post discharge about concerns related to care or service during their stay.

The procedure for complaint/grievance is including, upon receiving a complaint from a patient or duly authorized representative, every effort will be made to resolve the issue at the time of the complaint. Department management will reach out to the patient/family. Complaints that are not resolved will then follow the grievance process. Documentation will be entered in the electronic event reporting system as part of the incident reporting process. Grievances submitted to Mercy Health including verbally shall be entered into the electronic event reporting system. These reports shall be monitored and managed by the patient advocate including investigation and follow-up.
The investigation of the grievance shall be conducted by the manager or director of the area involved in collaboration with the patient advocate.