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Based upon policy and procedure review, medical record review, and grievance review; the hospital staff failed to respond to a grievance within the specified time frame for 1 of 3 patients (patient #6).

Review of the hospital's policy, "Patient Complaints/Grievance" with an effective date of December 2013 revealed...patient grievances should be resolved within seven business days. Further review revealed "in cases where resolution does not occur" within seven business days, "a written response must be provided to the patient immediately after the 7th business day indicating projected time of response. This should occur every fifteen business days until the grievance is resolved."

Closed record review conducted May 21, 2014 revealed Patient #6; a 27-year-old presented to Hospital XXX emergency department November 12, 2013 at 1419 with depression and suicidal thoughts with no suicidal plan. Further review revealed on November 13, 2013 at 1630, the patient was deemed stable and discharged from Hospital XXX emergency department to home accompanied by parent.

Review revealed on January 13, 2014; the patient submitted a complaint/grievance via email. Further review revealed the hospital responded to the complaint/grievance on February 18, 2014 (35 days later) and at which time, Hospital XXX closed the filed. Review revealed no documentation the hospital responded to the complaint/grievance in seven days nor in fifteen day increments.

Interview conducted May 22, 2014 at 0900 with administrative team member confirmed the hospital did not respond to the patient's complaint/grievance within the specified time frames.

Based upon policy and procedure review, medical record review, and quality improvement plan for a root cause analysis the facility staff failed to monitor the action plan for improvement of an adverse patient event for 1 of 1 sentinel event (root cause analysis) reviewed (Patient #3).
The findings include:
Review of the hospital's policy "Sentinel Event" dated July 2013 revealed " ...1. A 'sentinel event' is an unanticipated death or major permanent loss of function, not related to the natural course of patient's illness or underlying condition ...3. A sentinel event is also one of the following even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient's illness or underlying condition: ...Unanticipated death of a full-term infant ...B. 4 The root cause analysis must include: ...5. The (name of facility) Improvement Council will monitor compliance with follow-up action plans and analyze sentinel event occurrences for performance improvement opportunities...b. Where improvement actions are planned, identified who is responsible for implementation, when the action will be implemented (including any pilot testing), and how the effectiveness of the actions will be evaluated ..."
Review of the Root Cause Analysis (RCA) dated 09/13/2013 revealed "Event and Date of Event: L&D (labor and delivery) Unexpected newborn death, 08/20/2013" for patient (pt) #3. Review of the event revealed a 39 year old Gravida 2 (pregnant two time) Parity 0 (number of infants delivered was none) admitted to the facility on 08/16/2013 for induction of labor after a nonreassuring NST (nonstress test-test done to assess fetal wellbeing) and postdates (due date 08/06/2013, 42 weeks gestation). Continued review revealed on 08/20/2013 at 1524 the infant was delivered by cesarean section with Apgar scores (score given at birth to evaluate physical condition) of 0 (scale of 0 - 10 with 10 being the best; 0 = no heart rate, no respiration, no movement) at one minute and 0 at five minutes after birth. CPR (cardio pulmonary resuscitation) was initiated and the infant placed on life support. Continued review revealed life support was withdrawn that same evening and the infant expired.
Review of the "Final Actions from Meetings" revealed eleven (11) final actions identified. Review of action plan #2 revealed "draft midwifery guidelines related to formalizing OB (obstetrical) consult." Review of action plan #3 revealed "The following policy/protocol changes are in place: OR (operating room) time outs: 1. the 'time-out' procedure for all Cesarean sections will be amended to include both maternal and fetal heart rate prior to anesthesia placement and prior to incision. Fetal Monitoring: 1. when assessing maternal vitals, specific assessment will be performed and documented for heart rate coincidence. 2. If maternal and fetal heart rates are within 5 bpm (beats per minutes) of one another, maternal pulse oximeter will be placed. 3. If maternal and fetal heart rates cannot be clearly distinguished, confirmation of fetal heart rate will be performed if the maternal and fetal heart rates are with 5 bpm of one another. A. FHR should be confirmed via ultrasound for patient in early labor, those with intact membranes, those who are not appropriate candidates for AROM (artificial rupture of membranes) and those with contraindications to invasive monitoring b. FHR may be confirmed via scale electrode in patient with ruptured membranes in labor ... " Continued review revealed no implementation dates and no measuring or evaluation of the effectiveness of action plan #2 and #3.
Interview on 05/21/2014 at 1037 with Administrative Staff #1 revealed "the plan has been implemented and the staff have been educated but I am not doing any ongoing monitoring or evaluation of the effectiveness of action plan." Interview confirmed the facility staff failed to monitor the action plan for improvement of an adverse patient event.
Interview on 05/21/2014 at 1420 with Administrative Staff #2 revealed "we have had six follow-up meetings to this root cause analysis. The corrective action plan is ongoing. We have made the policy changes and the time out changes but I do not have any ongoing monitoring of the effectiveness of the plan, we have no incidents but I am not doing any monitoring ..." Interview confirmed the facility staff failed to monitor the action plan for improvement of an adverse patient event.
NC00096487, NC00096168, NC00097397