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Based on hospital policy review, medical record review, email review, grievance log review, and staff interview facility staff failed to identify and investigate a grievance and provide a written letter of resolution to a complainant for 1 of 1 grievance (Patient #15)

The findings include:

Review on 08/29/2017 of a policy titled "Patient Grievance Management Process" reviewed on 09/20/2016 revealed "...Example of Patient Grievances ...2. A verbal complain regarding patient care from a patient or patient's representative that cannot be resolved and is either delayed, referred, requires more investigation, or requires further action for resolution... Response to a Grievance ...4. Within seven calendar days, the patient or legal representative will be contacted by the Office of Patient Experience to address resolution or notify the patient or representative that further investigation is required ..."

Review on 08/29/2017 of the closed medical record for Patient #15 revealed a 29 year old female who was admitted on 08/05/2017 at 0819 for IOL (Induction of Labor) and TOLAC (Trial of Labor after Cesarean) at 39 weeks of pregnancy. Review revealed Patient #15 had active problems of previous cesarean section complicating pregnancy with antepartum condition or complication of Type 2 diabetes mellitus. Review revealed Patient #15's vaginal exam was "okay" for Pitocin (medication to induce contractions) but the Fetal Heart Rate (FHR) was not reassuring (baby may not be getting enough oxygen). Review revealed Patient #15 went for cesarean section due to "Non-Reassuring FHR". Interview revealed Patient #15's infant Patient #12 required resuscitation after birth on 08/05/2017 at 1307 and took 6 minutes to get a heart rate back. Review revealed on 08/08/2017 at 0017 Patient #15's infant Patient #12 experienced cardiac arrest and the staff were unsuccessful in resuscitating the infant. Review revealed Patient #15 requested a full unrestricted autopsy and signed the consent for the autopsy. Review of a Spiritual Encounter note dated 08/10/2017 at 1456 revealed Patient #15 was surprised and angered that the autopsy was not performed on Patient #12 due to Patient #15 consented to organ donation.

Review on 08/31/2017 of an email from Office of Patient Experience to Risk Management dated 08/10/2017 at 1549 revealed Patient #15 was very distraught that the autopsy was not done and thought the facility was trying to hide something. Review revealed Patient #15's physician was notified as Patient #15 was going to continue to request answerers. Review revealed "someone needed to talk to patient #15

Review on 08/31/2017 of the Grievance Log revealed there was no grievance associated with Patient #15.

Interview on 08/30/2017 at 1442 with MD #1 revealed Patient #15 requested an autopsy to be performed on Patient #12. Interview revealed MD #1 followed up on the request for the autopsy a few days later and found that the autopsy was not done.

Interview on 08/31/2017 at 1410 with Administrative staff and Registered Nurse (RN) #1 revealed there was no incident report or grievance filed for this case. Interview revealed the email correspondence should have been considered as a grievance. Interview revealed "we need more training on this."

Based on review of policy and procedure, medical record review and patient and staff interview, the nursing staff failed to follow a patient's plan of care in 1 of 5 discharged patient plans of care reviewed. (Patient #3)

The findings include:

Policy and procedure review on 08/29/17 of "Discharge/Transition to Alternative Level of care (revised date September 2017) revealed, "...Meet with the patient and or family to confirm the discharge/transition plan. Communicate this plan with the multidisciplinary team, including at the Care Progression Meetings, on an ongoing basis. ..."

Closed medical record review on 08/29/17 for Patient #3 revealed, a 75 year old female patient was admitted on 05/30/17 with neck pain. Review revealed on 05/30/17 an "Anterior Cervical Discectomy Fusion C3-4 with Zero-P implant" and a "Posterior Cervical Fusion/Foraminotomy Level 1" (neck surgery), was performed on Patient #3. Review revealed the patient had difficulty weaning from ventilator support resulting in a transfer to the ICU on 05/30/17 at 2027 after surgery for a higher level of care. On 06/06/17 at 1630 Patient #3 was transferred to the ICU stepdown unit. Review of a "Clinical Social Work (CSW) Note" dated 06/07/17 revealed, "Pt (patient) transferred from 2s (south) to 3s. CSW provided handoff to unit CSW. A "Progress Note" dated 06/08/17 at 0814 by the surgeon revealed, "...discharge to SNF (skilled nursing facility) when she is stable and probable of transferred (sic) to skilled nursing facility. We'll plan to transfer to MedSurg (medical surgical) floor today will need to (sic) an overhead hoyer lift (equipment attached to the bed to help with movement)...." Continued review revealed a transfer order to the Med Surg unit was placed in the computer for Patient #3 on 06/08/17 at 0819. Review of a "Discharge Summaries" dated 06/08/17 at 0821 revealed, "... Admit Date: 05/30/17 Discharge Date: 06/09/17" Continued review revealed a discharged order was placed in the computer 0n 06/08/17 at 0839 with "...Order Info Expected Discharge Date: 06/10/17" and "Discharge Disposition: 03-Skilled Nursing Facility ..." Review of a CSW note date 06/08/17 at 1400 revealed, "...patients granddaughter called wondering why she was not contacted when she is point of contact. CSW bolded phone number in cart for future reference. Patient's granddaughter also wondering why patient is being discharged today when the plan has been for Friday. Will contact MD." Review of a CSW note dated 06/08/17 at 0453 revealed, "CSW unable to locate MD's pager number in amion or notes. Discussed with RN and she said that she has already explained to patient's family why she is being discharged. Review revealed patient#3 was discharged on 06/08/17 at 1614 to a SNF. Review revealed no documentation that a physician was contacted to clarify the discharge order.

Interviews with Patient #6 and Patient #7 during unit tour on 08/30/17 at 1530 revealed, the patients and family/care givers were aware of and involved in active discharge planning. Interview revealed the patient and/or family was able to discuss their needs and were aware of what services were being coordinated in anticipation for their discharges.

Interview on 08/30/17 at 1030 with Case Manager (CM) #1 revealed, she was assigned to Patient #3. Interview revealed the case manager's role was to perform an initial review to evaluate for discharge needs, recommend SNF placement, and work with SW to determine a patient's discharge needs. Interview revealed during the "Quality Collaborative" rounds that occurred on 06/08/17, Patient #3 was discussed and "I" told the team that the patient was stable and was scheduled for transfer to the floor and discharge in one to two days. Continued interview revealed CM #1 viewed the discharge order on the computer screen after the "Quality Collaborative" meeting ,but, "did not recall" if she opened the order up to review the details of the order which indicated the discharge was to occur at a later date. Further interview revealed when the discharge order showed up in the system, CSW #2 was notified by CM #1 to discharge Patient #3. Interview revealed prior to the incident, CM #1 would open up discharge orders and read all the details before proceeding with a discharge. Interview revealed CM #1 did not know that a dicharge order could be placed in the EMR prior to the intended discharge date.

Interview on 08/30/17 at 1030 with CSW #2 revealed, she was assigned to Patient #3. Interview revealed she discussed the discharge with Patient #3 and the patient's granddaughter. The granddaughter voiced concern regarding the discharge on 06/08/17 saying that Patient #3 was not supposed to be discharged until 06/08/17 as per discussion with MD #4. Continued interview revealed CSW looked up the MD #4's phone number and was unsuccessful. Interview revealed CSW #2 did not get in contact with MD #4, but, spoke with the bedside nurse. Further interview revealed CSW #2 viewed the discharge order on the computer screen, but, did not open the order up to review the details of the order which indicated the discharge was to occur at a later date. Interview revealed prior to the incident, CSW #2 did not know that a dicharge order could be placed in the EMR prior to the intended discharge date.

Interview with RN #3 on 08/30/17 at 1130 revealed, she discharged Patient #3. Interview revealed she received the information in the handoff report. Interview revealed Patient #3 questioned the discharge when she was informed by RN #3. Continued interview revealed the Patient #3's "daughter voiced concern and got upset" because MD #4 told them that Patient #3 would be discharged on 06/10/17. Continued interview revealed RN#4 asked the family if they "want me to call the doctor?" They said no, and had calmed down, so, MD #4 was not contacted. Interview revealed Patient #3 was discharged to the SNF. A few hours after Patient #3's discharge, MD #4 called and wanted to know why patient #3 had been discharged and not transferred to MedSurg as ordered. Further interview revealed RN #4 did not look at the discharge order, but, acted on the information provided to her during handoff report and from the CSW. Interview revealed prior to the incident, RN #3 did not know that a dicharge order could be placed in the EMR prior to the intended discharge date. Interview revealed, RN #4 should have contacted MD #4 to clarify the discharge order.

Interview on 08/30/17 at 1530 during unit tour with AS #5 and RN #6 revealed, the expectation was for staff to open the orders in the computer and read all details. Continued interview revealed the RN should contact the physician when there was a need to clarify an order. Interview revealed prior to the incident, AS #5 and RN#6 did not know that a dicharge order could be placed in the EMR prior to the intended discharge date. Further interveiw revealed nursing staff had not been made aware/reeducated that a physician could place an order for a discharge prior to the intended discharge date.

Interview on 08/30/17 at 1435 with RN #7 revealed, there had been an upgrade in the EMR system on July 23, 2017. The upgrade changed the way a discharge order looked in the system. When the discharge order was placed, the entire order would be displayed including details when selected on the computer screen. Continued interview revealed the ability for a doctor to place and order in the system for a discharge at a later date was an approved work flow process. Further interveiw revealed, RN #7 was unsure as to wheter nursing staff were aware/educated that a physician could place an order for a discharge prior to the intended discharge date.


Interview on 08/30/17 at 1500 with MD #4 revealed, he routinely started working on the discharge paper work prior to the day of discharge. Interview revealed he placed the order for discharge in the computer on 06/08/17 with a discharge date of 06/10/17. Interview revealed had there been any concern or need to clarify his order he was available by telephone. MD #4's medical group had a physician on call 24 hours per day. Interview revealed MD #4 had spoken to the family and the nurse indicating that Patient #3 was to be transferred to the floor and would have an anticipated discharge date of 06/10/17. Interview revealed MD #4 placed a transfer order to the MedSurg floor to occur on 06/08/17 and a discharge order to occur on 06/10/17 in the EMR (electronic medical record) on 06/08/17. Continued interview revealed he discovered Patient #3 was discharged when he remotely accessed the system to review her condition and status during the course of the day. When MD #4 discovered Patient#3 was discharged he immediately called the stepdown unit inquiring about why the patient was discharged and told RN #3 she should have called him to clarify the orders. Continued interview revealed MD #4 called the SNF and gave the staff specific care instruction and symptoms that they needed to watch for that would indicate the need for Patient #3 to return to the hospital. Further interview revealed MD #4 spoke with the IT&S (Technology) department and changes were made to the EMR order system as a result of the incident with Patient #3.

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