HospitalInspections.org

Based on interviews and record document review, the hospital (H) failed to identify and address one (patient (P)1) of a sample size of four patient/family member's (FM) concerns as a grievance and address them in a timely, reasonable manner. In addition, the facility did not follow its own grievance policy. P1's FM verbally expressed concerns regarding P1's care, submitted complaints on the website requesting a response, and contacted the corporate office. A complaint submitted on line is considered a grievance. In addition, whenever a FM requests a response from the hospital, the complaint is considered a grievance and all requirements apply. The facility lacked documentation of efforts were taken to resolve the issues.

Findings include:

1) P1 is a 97 year old, who lived at a foster care home. On 08/01/2022, she became unresponsive and was taken to the H Emergency Department (ED), where she was admitted with the diagnosis of Dementia, and Metabolic Encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function). P1 normally stayed in bed most of time but was usually conversant.

P1 had a Durable Power of Attorney for Healthcare Decisions, designating her FM as agent. She also had a POLST (Physician Orders for Life-Sustaining Treatment) dated 03/18/2020 which indicated:" Do not attempt resuscitation (DNR), comfort measures only (CMO-use medication by any route, ...positioning and other measures to relieve pain and suffering. Use oxygen, ...and manual treatment of airway obstruction as needed for comfort. ... No artificial nutrition by tube." The POLST was signed by P1's FM.

2) Review of P1's medical records, revealed the following: 08/01/2022, Admitting Physician (MD)1 notes: "Emergency room physician spoke with patient's daughter who is her POA. Daughter stated that she did not want any aggressive measures or bases [sic] interventions. Understands that she (P1) is at the end of life and just wants are [sic] comfortable. Hoping hospice can be arranged at care home. Stated that she is okay with basic investigation to determine likely time course. Hospitalist called to admit the patient." Basic infection workup done in the ED revealed positive COVID. The plan included "Comfort measures per daughters request," and social work and case management for hospice." Admitting orders included: Code status, do not resuscitate and strict NPO (nothing by mouth) due to her level of consciousness.

08/02/2022 12:31 PM, Nutrition note: "...Not seen in person today due to Covid isolation. Per report, she (P1) is terminal at age 97 with decreased responsiveness. Staff can encourage PO if she is alert and foods requested. ..."

08/03/2022 at 04:33 PM, Case Management (CM) note: " Phone conversation w(with)/daughter this afternoon. Daughter very upset stating patient was being "starved to death" then demanding CM "transfer her to H2 immediately," CM informed dau (daughter) this was out of an RN's scope and that transfers need to be determined by the hospitalist and receiving facility. CM attempted to end the conversation so hospitalist could be contacted. Daughter finally agreed. Phone conversation with hospitalist and update re (regarding) conversation w/dau provided. Hospitalist will call daughter. CM update: Per hospitalisit, daughter agreed to hospice services ..."
08/03/2022 at 04:32 PM, DO (Doctor of Osteopathic Medicine) order: "Oral Diet, Cardiac, Soft please sit up and assist with feeding. comfort feeds (food and drinks P1 wants)."
08/03/2022 at 04:48 PM, DO note : "Had a long conversation with patient's daughter- she was very upset that patient was npo (nothing by mouth). She says she did not understand what comfort measures was. after [sic] we talked for a long time, she says she is thankful we talked and has a better understanding of CMO, and the patient's need for hospice. We discussed comfort feeds and risk of aspiration. ..."

08/04/2022 at 04:28 PM, Unit Manager (UM) note: "Called and spoke with FM regarding visitation. Informed that she can visit her mom, despite her mom's COVID positive status, due to her being on comfort care. I let her know that we do allow exceptions on a case by case basis. ...FM had misunderstood and thought that she was not allowed to visit because she was unvaccinated. I informed her that was no longer the requirement and that our policy had changed. ..."

3) During an interview with P1's FM, she identified the following concerns related to her mother's hospitalization August 1 to August 8, 2022. 1) Medical record content regarding two conversations, one with the EDMD about CMO and one with the Case Manager (CM) regarding transfer, 2) Length of time P1 was not fed, 3) FM was not made aware of positive COVID results until a conversation with Registered Nurse (RN) about P1 eating, 4) Lack of timely response regarding her concerns.

4) Reviewed the facility policy titled "Complaints & Grievances from Patients," last reviewed 03/14/2022. The policy included: "A complaint is a verbal expression of dissatisfaction by a patient and/or family member about the care or services received at H. Most complaints should be addressed quickly and resolved to the patient and/or family member's satisfaction. When a patient raises a concern or complaint that is not promptly resolved to the satisfaction of the patient, the patient shall have the right to file a grievance. A grievance is a written complaint or an oral complaint that was not quickly resolved."
"Procedures: Complaint Process " "2. Patient and/or family may voice a complaint in person or by phone with any H employee, medical staff, or ..." "3. The staff member who receives the patient complaint in person or by phone about care or treatment at H will attempt to resolve the complaint promptly." "4. "A complaint should be resolved quickly. A complaint is considered resolved when the patient and/or family member is satisfied with the actions taken." "5. All complaints must be resolved within one business day. Complaints that take more than a business day to resolve should be considered grievances." "6. If a staff member cannot resolve the issue to the patient and/or family members' satisfaction, then the complaint will be referred to the Unit Manager or House Supervisor or designee." "7. The Unit Manager, ...will then attempt to resolve the complaint. If the Unit Manager, ... is unable to resolve the complaint in 24 hours, the complaint then will be considered a grievance, and the Unit Manager, ...will initiate the formal grievance process as outlined below." "8. The Unit Manager or .... Will initiate the grievance process by sending a complaint intake form to Risk management (RM) and Quality Assurance (QA)." "9. The RM or QA Department staff: a. Upon receipt of the grievance, the RM or Quality Assurance Department staff will record time and date that grievance was received, and a letter will be sent to the patient and/or family member stating the grievance has been received. In all cases, the letter will be sent to the patient and/or family member within 7 business days from the date that the grievance was received by either RM or QA. b. The certified letter, which is sent by RM or QA, will provide a plan for the investigation and resolution of the grievance. All grievances shall be resolved within 60 days business days from date of receipt. c. A grievance is considered resolved when a patient/family member is satisfied with the action taken. d. If H believes that it has taken appropriate actions to resolve a grievance, and the patient/family is still not satisfied, H1 will consider the grievance closed. Documentation should reflect all efforts to resolve the grievance. ... f. In an effort to resolve a grievance in a more timely fashion, face-to-face patient/family meetings may be held to resolve issues." "10. For unresolved grievances, Senior Management will: a. Function as the Grievance Committee and shall meet monthly to review grievance/investigation reports by RM or QA to make an interim or final decision for those cases which remain unresolved. b. The Complaint and Grievance Committee will then have 72 hours to formulate an action plan to resolve the grievance. c. The complaint and Grievance Committee may either address the grievance directly, ( ...) or may refer the plan back to Quality or Risk Management for implementation of the resolution action plan." "11. A final decision shall take no longer than 60 days from the date the grievance was originally received by either the RM or QA Department. ..." "12. The RM is responsible for processing grievances and ensuring that the process adheres to the timelines." "13. The Quality Department will maintain log of all active and closed grievances received by RM/QA. ..."

5) Review of the third (July, August, September) Quarter 2022 Complaint Log revealed there was no entry of a complaint/grievance regarding P1.
Review of the Complaint Review Meeting minutes dated 08/31/2022 did not include any review of a complaint/grievance regarding P1.

6) Request made for all documentation related to any complaint regarding P1, entries via website, internal emails etc.
The Marketing Director (MKD) provided the following documentation of complaints P1's FM submitted on the website: On 09/12/2022 at 06:33 AM, FM submitted a complaint. Comments included: " ... who may I talk to re: what happened with my mother at the er-being admitted into H. Already spoke with assistant at "compliance" as lead person did not respond. I believe I spoke with Chief Nurse Executive (CNE) when I inquired re: those not taking the covid injection not allowed in the hospital. I have a copy of my mother's records during her er/stay at H. I'd like to include that in my discussion. ..." On 09/16/2022 at 09:03 AM, FM submitted another entry online. Comment: "Complaint" On 09/16/2022 at 01:31 PM, the MKD emailed the RM: "AST RM has talked with this family member and is aware of the situation. Although FM mentions CNE and our CEO (Chief Executive Officer), I believe this family's complaints are better managed by you (RM)." On 09/19/2022 at 10:33 AM, the MKD added in the system: "Third contact form submitted. Risk and Compliance are managing this complaint." On 09/22/2022 at 01:07 AM, FM submitted another entry. Comments included: "Please have ceo-acting ceo contact me (FM)."

Emails referencing P1's complaint: 10/10/2022 10:22 AM, From CEO Executive Assistant (EA) to RM: "FM called to speak with ICEO (Interim Chief Executive Officer) again. Did you follow-up with her after his conversation yet? ..." 10/10/2022 10:26 AM, From RM to EA: "Yes, I'll give her a call." 10/10/2022 12:45 PM, Email from RM to ICEO: Informed ICEO FM had no interest to speak with him (RM) and only wanted to talk to the ICEO. 10/19/2022 09:45 AM, From EA to RM: "FM called this morning asking for ICEO. She wants to follow-up and provide additional information." 10/19/2022 10:04 AM, From RM to EA: "...I called her last week and she refused to speak with me. Said she only speaks with ICEO now. ..."

7) Reviewed the "complaint intake form" initiated 10/24/2022. The Date/Time of event was noted as 08/01/2022, and indicated the complaint was reported "Verbally." Summary of the complaint or Grievance was: "Patients (P1) daughter had concerns regarding her mother's care when admitted in august of this year. FM had discussed these concerns with Nurse Manager of MS2 (nursing unit) where mother was located. Sound [sic] Physician caring for her mother, Case Manager (CM) assigned to case. Assistant Risk Manager (AST) from RM (Risk Management) also spoke at length with FM, who insisted that; "This is not a complaint." FM declined to speak with RM, and "I only want to speak with ICEO." After speaking with ICEO, we then categorized this discussion as a complaint/grievance. Issue appears to be FM's concern that her mother received no food during first two days at Hospital in august. At that time, the patient, P1 was unable to eat because of decreased level of consciousness and would have been a considerable risk for aspiration. Patient cleared her encephalopathy after two days at Hospital, at which point feedings were resumed. ..."
Actions Taken and /or Recommendations: The form was marked "No Further action," and indicated a certified letter was sent to the FM on 10/24/2022. The form included an area to indicate if the complainant was satisfied, it was marked "Yes." Documentation included: P1 has a valid Advanced Directive, of which FM is the primary POA. This form, which was drafted almost a year and a half before this admission, gave detailed instructions on P1's end of life wishes. P1 was assigned a status of "CMO" after arrival to ED from Care Home. At time of admission, P1 was unable to take nutrition by mouth. Given the notation of her AD (advanced directive) regarding "no artificial nutrition", neither a tube feeding, or parenteral nutrition was initiated, nor indicated at that time. FM was sent a letter on 10/24 with a copy of the AD and POLST form outlining her mother's wishes for end of life care. ...:

There was no letter sent acknowledging FM's grievance prior to sending the final letter on 10/24/2022.

8) On 11/10/2022 at 10:30 AM, during an interview with the AST, she said she initially took the call from P1's FM, when her mom was still in the hospital (08/01/2022 -08/07/2022) and she wanted to know why we weren't feeding her. The AST said she told the FM someone would call her and then told the UM. She went on to say, it was in the beginning of September the FM called and said she had tried to get ahold of RM for a long time. At that time, she "insisted it was not a complaint." She (FM) also said she had talked to multiple people and there was something wrong in the record. She said she had been leaving messages for RM, and she feels if she hadn't called, her mother would have starved. The AST said FM asked her what filing a complaint would do, and she told her "Put caregivers on alert what your concerns were." The FM said she did not want to do that. The AST said she did not hear anything for quite a while and then she got a call from corporate Risk Management, which was the same day or day after the ICEO spoke with FM. She went on to say she and the RM discussed the situation with corporate, and apparently FM had contacted "Civil rights." When asked the AST if FM had submitted anything online, she said "she may have, but did not recall." The AST said she felt sad that FM was so angry, and that she told the CM she wanted her mom to go to another hospital.

On 11/10/2022 at 10:32 AM, during an interview with Unit Manager (UM), she said she did not remember who asked her to call P1's FM regarding a concern, either the RM, or AST. She said from her recall, the ED physician had a conversation with P1's FM, when P1 was in the ED about P1's advanced directive (AD), that indicated she was DNR/CMO. She said P1's COVID test came back positive, and felt there was a misunderstanding FM couldn't visit because she (FM) was unvaccinated. The UM went on to say, they don't usually allow visitors if a patient is COVID positive, but do make exceptions of the patient is "CMO," and on a "case by case basis". She was not sure who communicated to FM she couldn't visit. The UM said she was aware of some concerns about the NPO status, and thought FM spoke with the primary nurse who contacted OD. The UM said she knew the charge nurses had multiple phone calls about the issue. She said she was not aware of any concerns about the CMO and to her recall, the only issue she addressed with FM was visitation. The UM said the RM called her after P1's discharge regarding a "civil rights issue," but she was not asked to investigate.

On 11/10/2022 at 11:27 AM, during an interview with the MKD, she said the H website allows people to submit complaints online. She said it will either go directly to RM, or she will forward the information. The MKD said they try respond in 24-48 business hours. She said P1's FM submitted requests (complaints) via the website "three to four times."

On 11/10/2022 at 08:30 AM, during an Interview with the RM, he described the process of how complaints are handled. He said the complaint is referred to the department manager, who had the most contact with the patient for investigation and follow up with the complainant. The RM confirmed the process as described in the policy. He said if the complaint involved medical care, they would involve physician to do case review, and if it becomes a bigger issue, once a month senior management reviews and assist with resolution. The RM said he couldn't remember who first called him, the UM or CM, but it was when P1 was still in the hospital and wasn't being fed. RM went on to say why P1 wasn't fed and that she had an AD and POLST with no artificial nutrition. He said P1's condition improved, and she woke up day three and could eat again. He said he "thought the issues were resolved, but continued," and she continued to talk to the UM, CM and Doctor. The RM said the AST spoke with her over an hour, and he tried to call her (FM) as well, but now she only wanted to talk to the ICEO. He said she seemed angry about the CMO, but we abide by whatever the patient wants. He said he was "pretty sure the ED doctor talked to her." When inquired why FM's concerns had not been identified and treated as a grievance, he said when the AST spoke with the FM, she asked if she wanted to file a complaint several times and the PR insisted it was not a complaint. The RM said it seemed like wanted information and she wanted to be heard. "Something happened to her mother, and she wanted to talk to the ICEO." The RM said he was aware FM had submitted complaints via the website. Requested documentation of the timeline, when and who took the initial and other complaints and what action had been taken, which was not provided prior to survey exit.

On 11/10/2022 at 08:00 AM, during an interview with the ICEO, he said he spoke with P1's FM twice, once in the middle of September and again in October, when she would not talk to anyone else. The ICEO said she was mad about P1 being COVID positive. He did recall the FM mentioned something about the records. The ICEO said he listened to her concerns, referred to RM, and asked him to reach out to her.