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Based on interviews with the Complainant and the Risk Manager, review of the Hospital's response letter to Patient #2 and the Hospital's policy and procedure related to grievance/complaint, it was determined that the Hospital failed to indicate the steps taken on behalf of the patient to investigate the grievance/complaint and the result of the grievance process in its written response letter dated 1/6/12.


Findings include:


The Complainant was interviewed on 1/26/12 at 12:50 P.M. The Complainant provided a copy of the Hospital's response letter dated 1/6/12. The Complainant said the letter was vague, nonspecific and did not directly address the issues presented in the complaint. The Complainant said the response did not meet his/her informational needs.


The Risk Manager was interviewed on 1/30/12 and 1/31/12 at 10: 30 A.M. The Risk Manager said a complaint was filed regarding care provided by ED Technician #1 on 1/1/12 during Patient #2's ED visit. The Risk Manager said she sometimes reviews the response letters written by the Hospital's Patient Relations Coordinator before the letter is mailed. The Risk Manager said she did not review the Hospital's letter sent to Patient #2 before it was mailed.


Review of the Hospital's written response to Patient #2 indicated that an investigation was performed regarding the patient's concerns and appropriate action was taken with the individual involved in the patient's care. The letter also apologized for any inconvenience that was caused to the patient during his/her stay.


Review of the Hospital's policy and procedure titled Patient Complaints and Grievances indicated that the Hospital's response letter will include the steps taken on behalf of the patient to investigate the grievance/complaint and the result of the grievance process.

Based on review of 2 (Pt #1 and Pt #2) of 10 medical records, the Hospital's Internal Investigations regarding Pt #1 and Pt #2 and interviews with Hospital staff, it was determined that the Hospital failed to identify all opportunities for improvement.


Findings include:


A) Documentation by a member of the Department of Anesthesia regarding a disclosure discussion of the medication error which occurred on 1/4/12 in the OR was not written in Patient #1's medical record as required by Hospital policy/procedure.

1.The Attending Anesthesiologist was interviewed on 1/31/12 at 8:30 A.M. The Attending Anesthesiologist said that he attended a family conference on Friday 1/6/12 where they discussed the medication error with Patient #1's family. The Attending Anesthesiologist said that the Hospital's President and CEO, Chair for the Department of Anesthesia,Risk Manager and he were present at the meeting.

2. Review of Patient #1's operative report, dated 1/4/12 indicated that a medication error occurred in the operating room when the Attending Anesthesiologist gave norepinephrine in error, instead of the intended normal saline to measure cardiac output.

3. Review of the Hospital's policy and procedure titled Communication of Unanticipated Outcomes indicated that the disclosure should be documented in the patient's medical record. Documentation should include a brief summary of the discussion, as well as when the discussion occurred and who was present at the time.



B) Review of Patient #2's ED medical record, dated 1/1/12, indicated that Patient #2's pain was not properly assessed and managed in the Emergency Department (ED).

1. Review of Patient #2's ED record indicated that Patient #2 presented to the ED on 1/1/12 at 1:09 P.M. with complaints of constant rectal pain. During the Triage assessment phase, Patient #2 rated his pain as 6 out of 10 (utilizing a 0-10 pain scale, 0 indicates no pain with 10 indicating the worst pain). Patient #2's ED record indicated that Patient #2 did not receive pain relief measures for three and a half hours after reporting pain at a level of 6. At 4:45 P.M, Patient #2 was reassessed for pain and reported the pain as level 5. Review of Patient #2's ED record indicated the ED Attending ordered Dilaudid at 4:40 P.M. and Nurse #2 administered Dilaudid at 4:45 P.M. No further pain assessment was documented and Patient #2 was discharged home at 5:45 P.M.

2. The ED Attending Physician was interviewed on 2/2/12 at 12:30 P.M. The ED Attending said that Patient #2 complained of rectal pain. The ED Attending said that at the time he examined the patient, a narcotic was not needed, but this was his assumption and he maybe could have offered the patient something for pain.

3. Review of the Hospital policy and procedure titled "Patient Assessment and Management Policy" indicated that every patient has the right to a consistent approach to the management of pain. Patients will be informed regarding options available for pain management and can expect information about pain and pain relief measures from staff. The policy also indicated that assessment/reassessment of pain will occur during and after a known pain producing event/procedure and pain management interventions will be provided.

Based on review of one (Pt #10) of 10 medical records, the Hospital's policy/procedure regarding allergies required the application of a red allergy band, however, the policy/procedure did not require documentation to indicate that in fact the band was placed on the patient.


Findings include:

Review of Pt #10's ED record indicated the patient came to the ED on 9/12/11 at 3:10 P.M. Pt #10's ED record indicated he/she had an allergy to Levaquin. The ED record indicated that Levaquin was ordered by a physician and was then administered by a nurse at 6:45 P.M.

Review of the Hospital's policy and procedure related to patient allergies indicated that patients with allergies will wear a red identification band with Allergies written in ink, in addition to the standard identification band. A registered nurse (RN) is responsible for placing the red identification band on the patient. The policy and procedure did not include that the RN responsible for the application of the red identification band was accountable for the application of the allergy band because the policy/procedure did not require documentation or a check off to ensure that in fact the red identification band was placed on the patient.

Based on review of 2 (Pt #1 and Pt #2) of 10 medical records, the Hospital's Internal Investigations regarding Pt #1 and Pt #2 and interviews with Hospital staff, it was determined that the Hospital failed to identify all opportunities for improvement.


Findings include:


A) Documentation by a member of the Department of Anesthesia regarding a disclosure discussion of the medication error which occurred on 1/4/12 in the OR was not written in Patient #1's medical record as required by Hospital policy/procedure.

1.The Attending Anesthesiologist was interviewed on 1/31/12 at 8:30 A.M. The Attending Anesthesiologist said that he attended a family conference on Friday 1/6/12 where they discussed the medication error with Patient #1's family. The Attending Anesthesiologist said that the Hospital's President and CEO, Chair for the Department of Anesthesia,Risk Manager and he were present at the meeting.

2. Review of Patient #1's operative report, dated 1/4/12 indicated that a medication error occurred in the operating room when the Attending Anesthesiologist gave norepinephrine in error, instead of the intended normal saline to measure cardiac output.

3. Review of the Hospital's policy and procedure titled Communication of Unanticipated Outcomes indicated that the disclosure should be documented in the patient's medical record. Documentation should include a brief summary of the discussion, as well as when the discussion occurred and who was present at the time.



B) Review of Patient #2's ED medical record, dated 1/1/12, indicated that Patient #2's pain was not properly assessed and managed in the Emergency Department (ED).

1. Review of Patient #2's ED record indicated that Patient #2 presented to the ED on 1/1/12 at 1:09 P.M. with complaints of constant rectal pain. During the Triage assessment phase, Patient #2 rated his pain as 6 out of 10 (utilizing a 0-10 pain scale, 0 indicates no pain with 10 indicating the worst pain). Patient #2's ED record indicated that Patient #2 did not receive pain relief measures for three and a half hours after reporting pain at a level of 6. At 4:45 P.M, Patient #2 was reassessed for pain and reported the pain as level 5. Review of Patient #2's ED record indicated the ED Attending ordered Dilaudid at 4:40 P.M. and Nurse #2 administered Dilaudid at 4:45 P.M. No further pain assessment was documented and Patient #2 was discharged home at 5:45 P.M.

2. The ED Attending Physician was interviewed on 2/2/12 at 12:30 P.M. The ED Attending said that Patient #2 complained of rectal pain. The ED Attending said that at the time he examined the patient, a narcotic was not needed, but this was his assumption and he maybe could have offered the patient something for pain.

3. Review of the Hospital policy and procedure titled "Patient Assessment and Management Policy" indicated that every patient has the right to a consistent approach to the management of pain. Patients will be informed regarding options available for pain management and can expect information about pain and pain relief measures from staff. The policy also indicated that assessment/reassessment of pain will occur during and after a known pain producing event/procedure and pain management interventions will be provided.