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Based on record review and interview, the hospital failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in its resolution of the grievance, in that, the hospital did not provide 3 of 4 patients (Patient #1, #2, and #4) with written notice of resolution (to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion) for the patient care complaints received after the patient was discharged from the facility.

Findings included

Patient #1's date of service was 6/07/16 through 6/09/16. The hospital documented a complaint/grievance on 6/14/16 in regards to physician knowledge. The hospital did not provide the patient with written notice of its decision.

Patient #2's date of service was 6/01/16. The hospital documented a complaint/grievance on 6/08/16 in regards to misdiagnosis. The hospital did not provide the patient with written notice of its decision.

Patient #4's grievance was logged on the complaint log on 8/01/16. There was no description or follow up on the complaint documented/available for review. The hospital letter sent to the patient acknowledged the grievance with no detail. The hospital did not provide the patient with written notice of its decision.

During an interview on 3/01/17 at 1:00 PM, Personnel #2 was asked for the written resolution letter for Patient #2. Personnel #2 stated, "There were no letters."

During an interview on 3/01/17 at 2:20 PM, Personnel #5 was asked for the written resolution letter for Patient #1 and #4. Personnel #5 stated, "They do not have them."

The June 2016, last revised "Patient Complaints/Grievances" policy required, "Grievance means an oral or written complaint that is not immediately resolved at the time of the complaint by staff present...billing issues are not considered a grievance unless the complaint also contains elements addressing patient service or care issues...grievance will be followed up with a written notice of decision..."

Based on record review and interview, the hospital failed to ensure the right of the patient, in collaboration with his or her physician, to make decisions involving his or her health care, in that, 9 of 9 (Patient #1, #2, #3, #5, #6, #7, #8, #9, and #10) emergency room patient records did not document the right of the patient, in collaboration with his or her physician, to make decisions involving his or her health care.

Findings included

Patient #1's, #2's, #3's, #5's, #6's, #7's, #8's, #9's, and #10's emergency room records did not document the physician explanation of tests to be performed during the visit which did not allow for the right of the patient to collaborate with his or her physician, to make decisions involving his or her health care.

During an interview on 3/01/17 ending at 1:50 PM, Personnel #6 was asked to see where the ER doctor told the 9 patients about the tests that would be performed. Personnel #6 stated, "No, I know it is not there."

During an interview on 3/01/17 ending at 2:05 PM, Physician #10 was asked about his follow-up on the hospital's complaint from a patient not being told about a CT Scan by the emergency room doctor. Physician #10 stated "We (doctors) have not documented discussing tests with patients in the past, only results."

Based on record review and interview, the medical staff failed to ensure a physical examination was placed in the patient's record, in that, 1 of 9 (Patient #3) registered, emergency room, patient record did not document a physical examination by the emergency room physician.

Findings Included

Patient #3's 7/01/16 electronic emergency room record did not document a physical examination by the emergency room physician.

During an interview on 3/01/17 ending at 11:50 AM, Personnel #4 was asked for the physical examination by the emergency room physician for Patient #3. Personnel #4 stated, "I don't see it."

During an interview on 3/01/17 at 2:40 PM, Physician #10 stated, "(Physician #12) did not have a physical exam in (documented in the record). (The physician) will be in today and I will have (the physician) document it (addendum)."