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Based on medical record review, policy review, complaint/grievance log review and staff interviews, the hospital failed to ensure it thoroughly investigated grievances and provided a written response in accordance with hospital policy.

Findings included:

The hospital failed to ensure and promote the rights of each patient. The hospital did not have documented evidence of timely investigation of complaints from or on behalf of nine patients (Patient #'s 5, 7, 11, 12, 14, 15, 16, 17 and 18) and one physician regarding patient care. This could affect any patient who presented to the emergency department. The emergency department has a capacity of 33 with a daily average census of 205 patients. Please refer to A119.


The hospital failed to investigate and resolve systematic problems indicated by the grievance. The hospital did not provide the patients with a written response of their resolution/decision grievances in a timely manner based on the hospital's policy. Please refer to A123.

Based on open and closed record reviews, review of policies and procedures and interviews with staff, it was determined the hospital failed to ensure and promote the rights of each patient. The hospital did not have documented evidence of timely investigation of complaints from or on behalf of nine patients (Patient #'s 5, 7, 11, 12, 14, 15, 16, 17 and 18) and one physician regarding patient care. This could affect any patient who presented to the emergency department. The emergency department has a capacity of 33 with a daily average census of 205 patients.

Findings include:

Patient #5 was seen in the emergency department on 6/3/2011 at 5:55 PM with a complaint of acute upper quadrant pain, nausea and vomiting. The patient complained of a delay in treatment and being stuck by needle when the patient rolled over in bed. The patient further complained that the staff stated they were waiting on the lab result, however, Patient #5 was a lab employee and stated he/she called the lab and the lab reported the results had already been sent some time ago. There was no follow up to the patient's concerns.

Patient #7 was seen in the emergency department on 8/18/2011 at 6:22 PM with a complaint of abdominal pain with nausea and vomiting. The patient was admitted to the hospital with acute gastroenteritis, uncontrolled diabetes and congested heart failure. The patient filed a complaint on 8/26/2011 that the emergency department staff caused significant amount of bruising on bilateral upper arms from the elbow to shoulders and that the bruising occurred from the blood pressure cuff. This patient was on plavix and coumadin (potential for bleeding). The only documentation of follow up with the emergency department staff was an e-mail to the emergency department staff from the department manager which ask the staff, " What could we have done to prevent this? Taken the cuff off between readings? Loosened the cuff as she asked? Lots of possibilities." Out of 126 emergency department staff, there were only 2 staff who responded. There was no documented evidence of any follow up. There have not been any systematic follow up and/or response regarding this issue. Staff C was interviewed on 8/7/2011 at 2:00PM and he/she stated that although the patient sustain harm as a result of the application of the blood pressure cuff, the complaint was consider closed after talking to the patient at the bedside.

Patient #11 was seen in the emergency department on 06/26/11 with complaints of dizziness, difficulty in walking and confusion. The patient was evaluated and discharged. The patient's primary physician contacted the hospital on 07/26/11 to report the patient's wife had stated the patient continued to have the same symptoms after discharge. The patient was transported to another hospital where he/she was found to have a "large cerebral hemorrhage (bleeding in the brain)". The facility documentation revealed hospital staff spoke with the patient's wife on 07/26/11. The documentation revealed the wife confirmed what had been reported, and also stated the patient had experienced a similar situation in March, 2011 when he was misdiagnosed and the emergency department failed to manage pain during the episode. The documentation revealed a peer review had been completed on the 6/26/11 medical record, but lacked evidence any investigation had been done into the allegations surrounding the March 2011 visit.

Patient #12 was seen in the emergency department on 7/6/2011 at 2:46 PM with complaint of being assaulted with complaints of nose and hand pain and abrasions of the face. The patient was discharged from the emergency department on 7/6/2011 at 4:36 PM. The patient's daughter called the hospital on 7/7/2011 at 4:53 PM and reported the radiologist report states the patient had 3rd and 4th metacarpal bones were fractured and the hospital did not do anything. The chart was reviewed the and verified that the daughter was correct. The physician advised them to return to the emergency room for a splint. The patient returned and received ulnar gutter splint, sling and pain medication. There was no documentation and/or peer review that indicated that any follow up was done to prevent this concern from happening again.

Patient #14 was seen in the emergency department on 7/4/2011 at 5:56 PM with pain associated with a kidney stone which was the patient's 4th similar episode. The patient requested that his physician be notified of the situation. The emergency room physician order a CT which showed a 4 mm stone. The patient was discharged with a prescription for pain medication and instructions to follow up with his physician. The patient complained on 7/4/2011 at 11:00 PM that the hospital failed to adequately manage his pain and the physician in the emergency room treated him rudely showing a lack of caring. The patient was unable to get pain medication ordered due to 7/4/2011 being a holiday and late hour. The patient saw his physician on 7/5/2011. The physician sent him to a facility for stone manipulation and insertion of stent. There were no documented evidence that the patient's concerns were addressed and/or followed up by the hospital.

Patient #15 was seen in the emergency department on 9/7/2011 at 3:02 PM with complaint of severe rectal pain. The patient was admitted to the hospital. The patient's granddaughter called and complained on 9/9/2011 that her grandmother received a pain medication that she was allergic to. Previous emergency room admissions and this admission for this patient indicated that the patient did receive the medication in question. Notation was found in previous documentation that it was the patient's and family preference for the patient not to receive the medication in question because the medication caused the patient to hallucinate. The record review by the hospital staff indicated that the family needed education that the patient is not allergic to the pain medication. When questioned regarding consideration of the patient's/family's preference and the right to refuse, Staff D stated that their preference was not considered. A letter was sent to the patient on 10/4/2011 stating that the investigation is not completed.

Patient #16 was seen in the emergency department on 8/14/2011 at 3:05 PM with complaints of right jaw, right ankle, bilateral leg and right elbow pain. There was a delay in treatment in excess of 5 hours due to 6 physicians not in agreement. A complaint was voiced on 8/14/2011 by the hospitalist. On 8/14/2011 a review of the medical record and staff G follow up note on 10/6/2011 at 4:00 PM, the patient was seen by staff G who indicated that the patient's chief complaint was a broken jaw and he/she got the history from the patient with a swollen leg for over a week. An ultrasound indicated the patient had a deep vein thrombosis (DVT). Staff indicated that he/she felt the patient really needed to be admitted for the DVT (a life threatening condition) which took precedence over the broken jaw. Staff called the hospitalist and the physician on call. The physician (staff H) on call stated that he did not do jaw surgery and to call another physician (staff J). The physician called back and said that physician J (staff J) said not to admit any trauma. Staff G stated the reason the patient was being admitted was for DVT not for trauma because if the patient just had a jaw fracture the patient would be sent home. Nevertheless physician J (Employee J) refused the patient. Physician K (staff K) was paged several times before he called back at 8:46 PM. The patient was finally admitted at 11:25 PM. The outcome notes dated 8/24/2011 stated the above concern was resolved as the patient was finally admitted by the hospitalist. However, as of 10/11/2011 there was no documented evidence of a peer review or any actions to prevent the delay in treatment in response to the above identified problem/issue. This was verified with staff C and D on 10/11/2011 at 2:00 PM.

Patient #17 was seen in the emergency department on 7/4/2011 at 5:00 PM with a complaint of muscle spasms. The patient and spouse complained of increase weakness and confusion. The emergency physician ordered blood and radiology tests. The primary care physician was notified. The emergency physician discharged the patient home. The patient's spouse was very uncomfortable with the patient being discharged. The emergency room physician told the nurse to attempt to ambulate the patient. The patient ambulated with difficulty, "unsteady, dragging left leg." Spouse voiced verbal complaint stating OSU Neurology was not consulted for a possible transfer. There was no documented evidence of any follow up actions taken. A response letter from the hospital was sent on 8/5/2011 regarding staff's failure to listen to the concerns of the patient and spouse and the concern of the alleged physician's rude treatment. There was no peer review.

Patient #18 was seen in the emergency department on 7/11/2011 at 12:18AM with complaint of headache and elevated blood sugar. The patient called in a complaint on 7/13/2011. The patient stated during the visit to the emergency department that the staff was not professional; talking among themselves for forty five minutes and then 30 minutes later the physician came in who could not hear; then another physician came in 30 minutes later. Patient left without receiving prescriptions because the nurse would not explain and had an attitude. There was no documented evidence that there was any follow up regarding this patient's concerns. Staff C stated that there is no documented follow up with the physician and/or nursing staff regarding the above issue voiced.

Information was provided on 10/03/11 regarding a complaint filed by a Hospitalist (physician hired by the hospital to provide care to inpatients). The documentation stated this was not a grievance, and the report was filed on 09/26/11. The documentation revealed the hospitalist (Employee L) had called the physician quality hotline regarding "unnecessary admissions from the ED (Emergency Department)". Employee L cited two examples of patients he/she felt were inappropriately admitted. The documentation lacked evidence any investigation had been completed or any resolution reached regarding the physician's concern. The documentation revealed a meeting had been scheduled for 10/12/11 (16 days after the concern was received) between two physicians to discuss the issue.

These findings were confirmed with Employee B on 10/11/11 at 2:00 P.M.

Based on staff interview, complaint log, and record reviews the hospital failed to investigate and resolve systematic problems indicated by the grievance. The hospital did not provide the patients with a written response of their resolution/decision of the grievances in a timely manner and/or based on the hospital's policy.

Findings Include:


The hospital policy and procedure titled, " Patient Compliant, Grievance and Appeal Process (#RS36)" indicates that the hospital will respond in writing to the complainant. If the hospital does not have a resolution in 7 days of the initial complaint, notification of the delay will be given to the complainant. Then the hospital will follow-up within 5 working days with a written response to the grievance and the steps taken to resolve it.

The hospital staff did not follow the above policy and procedures for the following patients:

Patient #5 complained on 6/6/2011. The letter was sent on 6/ 21/2011.

Patient #7 voiced a complaint on 8/18/2011. No letter has been sent as of 10/07/2011.

Patient #12 voiced a complaint on 7/7/2011. The letter was sent on 8/5/2011.

Patient #14 voiced a complaint on 7/4/2011. The letter was sent on 8/5/2011.

Patient #15 voiced a complaint on 9/9/2011. The letter was sent on 10/4/2011 stating the investigation was not completed and the complainant will be notified when the investigation was completed.

Patient #16 voiced a 8/17/2011. No letter was sent as of 10/11/2011.

Patient #17 and spouse voiced a complaint on 7/5/2011. The letter was sent on 8/5/2011.

Patient # 18 voiced a complaint on 7/13/2011. The letter was sent on 8/5/2011.

These findings were confirmed by Employee C on 10/11/11 at 3:30 P.M.

Based on medical record review and staff interview, the hospital failed to ensure the medical record contained information regarding ordered services including a mental health evaluation and urine test. This affected one of one patient reviewed with a mental health evaluation (Patient #22). The total sample reviewed was 22 medical records.

Findings included:

The medical record for Patient #22 was reviewed on 10/07/11. The patient was brought to the emergency department by an ambulance on 09/23/11. The patient's chief complaint was suicidal thoughts. The medical record contained an evaluation by the emergency department physician and an order was placed for a mental health evaluation. The nursing notes documented a mental health worker was present at the patient's bedside at 5:20 A.M. and 6:20 A.M. The medical record lacked documentation of the actual evaluation or the outcome of the evaluation. The medical record lacked evidence the ordered urine toxicology test was completed on Patient #22.

An interview was conducted with Employees B and C on 10/07/11 at 2:00 P.M. Both employees confirmed the mental health documentation was not part of the emergency department record. Employee B stated this was an ongoing concern and had been discussed with the community service agency which provides the mental health assessments. Employee B stated another meeting was scheduled on 10/18/11 to further discuss the issue.


This substantiated complaint number OH00062717.

Based on medical record review, policy review and staff interview, the hospital failed to ensure a process was in place to ensure patients were assessed in a timely manner to determine if their medical condition was stable enough to await assessment.

Findings included:

The medical record for Patient #9 was reviewed on 10/05/11. The medical record revealed the patient was admitted to the emergency department on 06/03/11 with complaints of abdominal pain. The record revealed the patient was assessed by a Registered Nurse (RN) and a triage acuity level was assigned. The patient was documented as leaving without treatment at 5:00 P.M. The record lacked documentation the patient was seen by a physician during that visit.

Patient #9 returned to the emergency department on 06/04/11 at 2:35 P.M. with complaints of right lower quadrant abdominal pain. The patient rated his/her abdominal pain as "5-10" on a 1-10 scale. The medical record revealed a triage assessment was not completed on the patient until 3:51 P.M., an hour and sixteen minutes after his/her arrival into the emergency department. The medical record lacked evidence anyone assessed the patient to determine his/her medical stability to wait for treatment.

The hospital policy titled "ESI Triage Algorithm", no policy number, was reviewed on 10/07/11. The policy lists the five triage ratings from level 1/critical to level 5/non-urgent. Acuity levels are assigned based on how quickly a patient requires medical treatment. Acuity level 1 stated the patient is in eminent loss of life; resuscitation; dying. Level 2 stated this is for patients who have conditions that may result in loss of life or limb, if not treated immediately. The policy lacked any information regarding when the triage assessment was to be completed for patients coming to the emergency department. The policy further lacked any information regarding how the hospital was to manage patients who were waiting to be assessed and assigned an acuity level or how it would provide care for critical patients while waiting to be triaged.

Employee D confirmed these findings in an interview conducted 10/06/11 at 11:00 A.M.