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Based on review of hospital Grievance Policy, review of Grievance Reports filed in the last 6 months, and interviews with administrative staff, the hospital failed to thoroughly investigate grievances or to have a process to evaluate the effectiveness of the hospital's investigative process for 3 of 6 (#6, 9, 11). Findings:


1. Review of the Grievance Report filed on behalf of patient #6 dated 4/14/11 revealed patient #1 was brought to the ED (emergency department) by her grandson with complaints of chest pain. Further review revealed documentation that physician told patient #6 her pain was due to a fall and she would be fine. Patient #6's grandson alleged poor ED care when he went to pick his grandmother up the next day and found her dead.

Review of the Grievance Report revealed S10 Patient Advocate obtained the ED record and reported to the Administrator. Further review revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director. There was no documented evidence that an investigation was initiated.

S10 was asked by the survey team during an interview to provide the investigative data regarding patient #6. S10 indicated she had spoken with the patient's grandson by telephone but confirmed there was no documented evidence that the hospital investigated the allegation.

2. Review of the Grievance Report filed on behalf of patient #9 dated 2/21/11 revealed patient #9 presented to the ED on 2/4/11 with complaints of "not being able to breathe". Patient #9 alleged she received substandard care by the physician and was told nothing was wrong with her. Patient #9 presented to a different ED later that day and was admitted for possible blood clot in her lung and was hospitalized for 5 days.

Further review of the Grievance Report revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director. There failed to be documented evidence the Administrator investigated the allegation against the ED physician. There was no documented evidence that an investigation was initiated by any staff.

3. Review of the Grievance Report filed on behalf of patient #11 dated 4/11/11 revealed patient #11 was brought to the ED with a complaint of fever and "being out of her mind". The ED sent her home with instructions to alternate Motrin and Tylenol (fever reducers) and that she would be fine. The family reported she was no better the next day and took her to a different hospital ED where patient #11 was diagnosed with pneumonia in both lungs.

Further review of the Grievance Report revealed S10 apologized on behalf of the hospital and explained the relationship the hospital has with the ED physicians. S10 reported she asked the complainant if they had any problems with hospital staff and the complainant responded "Just the doctor...no one else". S10 indicated she" thanked the complainant for bringing this situation to our attention and that the hospital could not correct problems unless we know they exist". Further review revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director. There failed to be documented evidence the Administrator investigated the allegation against the ED physician.

Interview with S10 Patient Advocate on 6/2/11 at 1:00 PM revealed she was responsible for grievance intake and for directing the grievance to the appropriate department to investigate. S10 stated if the issue referred to nursing care the DON investigated, or if it was about the ED physician staff, the Administrator investigated since the ED physicians were contracted. S10 also stated if the grievance was about ED personnel, the ED director investigated it. S10 confirmed there was no documented evidence the Administrator investigated the allegations made by patients #6, #9 and #11.

Review of hospital Grievance Policy (no date of approval indicated) revealed "The purpose of the Hospital Grievance Process is to allow full opportunity for patients, or the legal representatives, to seek and obtain an explanation and/or correction of any perceived failure of the hospital, its staff, agents or contractors to furnish the level or quality of care and/or services to which the patient or their legal representative may believe the patient is entitled to or other wise expect."

Based on review of grievances filed in the last 6 months, Grievance Policy (no date of approval) and staff interview, the hospital failed to include in the letter of resolution to the complainant the steps taken on behalf of the patient to investigate their grievance and the results of the grievance process for 4 of 6 grievances filed. (Patients #6, 8, 9, 11)

Findings:

1. Review of the Grievance Report filed on behalf of patient #6 dated 4/14/11 revealed patient #1 was brought to the ED (emergency department) by her grandson with complaints of chest pain. Further review revealed documentation that patient #6 was told her pain was due to a fall and that she would be fine. Patient #6's grandson alleged poor ED care when he went to pick his grandmother up the next day and found her dead.

Review of the Grievance Report revealed S10 Patient Advocate obtained the ED record and reported to the Administrator. Further review revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director.

Interview with S10 Patient Advocate on 6/2/11 at 1:00 PM confirmed that there was no documented evidence that the hospital sent a written notice of resolution to the patient's grandson. When asked why there was not a letter of resolution to the family, S10 stated she only had a phone number and the grandson worked off shore and she could never reach him. S10 confirmed she had no documented evidence of attempting to reach the patient's grandson.

2. Review of the Grievance Report filed on behalf of patient #11 dated 4/11/11 revealed patient #11 was brought to the ED with a complaint of fever and "being out of her mind". The ED sent her home with instructions to alternate Motrin and Tylenol (fever reducers) and that she would be fine. The family reported she was no better the next day and took her to a different hospital ED where patient #11 was diagnosed with pneumonia in both lungs.

Further review of the Grievance Report revealed S10 apologized on behalf of the hospital and explained the relationship the hospital has with the ED physicians. S10 reported she asked the complainant if they had any problems with hospital staff and the complainant responded "Just the doctor...no one else". S10 indicated she" thanked the complainant for bringing this situation to our attention and that the hospital could not correct problems unless we know they exist".

A follow up note on the Grievance Report dated 4/28/11 revealed an address was not available to send a follow up letter to the complainant, so a telephone call was made instead. S10 noted she thanked the complainant again for bringing this matter to the hospital's attention. "She was very pleased with my concern and follow up." Interview with S10 Patient Advocate on 6/2/11 at 1:00 PM confirmed there was no documented evidence of a written response that included the steps taken on behalf of the patient to investigate the grievance or the outcome of the resolution.

3. Review of the Grievance Report filed on behalf of patient # 8 dated 1/27/11 revealed patient #8 presented to the ED with severe abdominal pains. The complainant alleged the ED personnel staff was rude. The ED Director reviewed the chart and spoke with ED staff that worked that night who reported patient #8 was uncooperative and belligerent throughout the entire ED visit. The ED director counseled with the ER staff regarding customer service and appropriate behavior on the job. Further review revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director. Review of the response letter to the complainant failed to include steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

4. Review of the Grievance Report filed on behalf of patient #9 dated 2/21/11 revealed patient #9 presented to the ED on 2/4/11 with complaints of "not being able to breathe". Patient #9 alleged she received substandard care by the physician and was told nothing was wrong with her. Patient #9 presented to a different ED later that day and was admitted for possible blood clot in her lung and was hospitalized for 5 days.

Further review of the Grievance Report revealed a written report was sent to the Administrator, S8 DON, S9 Risk Manager and ED director. There failed to be documented evidence the Administrator investigated the allegation against the ED physician.

Interview with S10 Patient Advocate on 6/2/11 at 1:00 PM revealed she was responsible for grievance intake and for directing the grievance to the appropriate department to investigate. S10 stated if the issue referred to nursing care the DON investigated, or if it was about the ED physician staff, the Administrator investigated since the ED physicians were contracted. S10 also stated if the grievance was about ED personnel, the ED director investigated it. S10 confirmed there was no documented evidence of a written responses sent to patients #6, #9 and #11 that included the steps taken on behalf of the patient to investigate the grievance or the outcome of the resolution.

Review of hospital Grievance Policy (no date of approval indicated) revealed the following:
Procedure
9. Complainant will be notified in writing of decision and/or action taken within 5 business days of completion.