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Based on record reviews and interviews the hospital failed to ensure a patient's grievance was promptly identified; therefore, delaying implementation of the resolution process for 1 of 3 grievances reviewed (Patient #3) out of a total sample of 8. Findings:

Review of the hospital policy titled, "Patient Grievance and Complaints, #8610pr-13, last revised 1/10" presented by the hospital as their current policy revealed in part, "A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation, or a Medicare beneficiary billing compliant related to rights and limitations. Patient grievances would also include situations where patients or the patient's representative call or write to the hospital about concerns related to care or services, who were not able to resolve the concerns during their stay. . . All grievances will be addressed as quickly as possible. If unable to resolve within 7 days from receipt, a written notice of acknowledgement, including an estimated time for the final response, will be sent to the patient or their representative. A formal written response should be sent to the patient within 30 days of receipt of the grievance. If a resolution cannot be completed within 30 days, a letter will be sent to the patient or their representative, with an estimated time for the final written response. . . Any patient concerns that are complex or broad in scope will be handled through referral to the Patient Relations Department. This coordination simplifies contact for the patient. . . "

Review of Patient #3's daughters electronically documented "Inquiry" revealed in part, 10/11/2010: Patient Relations staff met with the daughter who had "questions and concerns" about her father's autopsy and did not want the attending physician to know of her request. #3's daughter was escorted to Chaplain (S36's) office. Further review revealed no documented evidence of the interaction between Chaplain 36 and Patient #3's daughter and no documented evidence of identifying the daughter's concerns as a grievance (See interview below with Chaplain S36 on 12/10/2010 at 1:10 p.m.). 10/11/2010 a meeting was held between Patient Relations Registered Nurse (RN) S37, Patient Relations Staff S38, and Vice President of Nursing S14 to discuss the case of Patient #3 in regards to Patient #3's daughter's inquiry request regarding the patient's autopsy. 10/12/2010 at 12:08 p.m.: Unit Director S11 provided a follow up call to Patient Relations indicating she had met with Patient #3's family. S11 indicated #3's daughter was seeking comfort and support. S11 indicated she was setting up an appointment with Physician S12, Vice President of Medical Affairs to speak with family (no documented date of meeting). 10/26/2010: Physician S12 was continuing to await the final results of the autopsy report before being able to determine the cause of death for Patient #3. 10/27/2010 at 1530 (3:30 p.m.): Patient #3's daughter called and implied she was not happy with her conversation with Physician S22 regarding the death of her father and wished to "escalate" her concern to the next level and speak with the Medical Director, Medical Examiner, and Chief Surgeon. Further Patient #3's daughter indicated if the hospital was not able to resolve the issue for her, she planned to report her concerns to the Department of Health and Hospitals (review revealed no documented evidence of identifying the family's concern as a grievance on this day). 10/28/2010 at 1440 (2:40 p.m.): Phone call from Patient #3's daughter requesting follow up - advised that Patient Relations was still investigating her father's case and someone would call her as soon as information was available. 11/08/2010 at 1148 (11:48 a.m.): Patient #3's daughter dropped off a letter dated 11/05/2010 where she stated she was not happy with the hospital's handling of her concerns and had filed a grievance with Department of Health and Hospitals. Patient #3's daughter also requested a meeting with the Pathologist that performed the autopsy on her father (#3). Classification of Inquiry moved to a "grievance" .

Review of Patient #3's daughters electronically documented "Grievance" revealed in part, Submission Date: 11/08/2010. 11/10/2010 at 10:00 a.m.: Patient Relations RN S37 spoke with Patient #3's daughter about grievance request. #3' daughter requested a meeting with Contracting Pathologist, another copy of Patient #3's Medical Record, and a meeting with an Ochsner staff member who could answer her questions. 11/10/2010 at 1415 (2:15 p.m.): Telephone call received from Pathologist (S39) that performed the autopsy on Patient #3 to Patient Relations Worker (S37). S39 indicated Pathologist do not meet with family members directly; however, S39 was willing to address any of the family ' s questions through the surgeon or clinician. 11/07/2010: Acknowledgement letter was mailed to Patient #3's daughter indicating her concerns were being reviewed and it was expected that a response letter would be mailed on 12/07/2010. 11/12/2010 at 1156 (11:56 a.m.): Phone Call to Patient #3's daughter for update which included; 1) still waiting on reply regarding a meeting to discuss her father's case, 2) an entire copy of the father's medical record had been mailed, 3) pathologist was willing to answer her questions through the surgeon or clinician. 12/03/2010 at 1845 (6:45 p.m.) : A decision was made not to meet with Patient #3's daughter because she had already met with Physician S22, Nursing, and the Vice President of Medical Affairs without satisfaction. "The organization feels they may not have all the answers to (Patient #3's daughter's) questions. Acknowledgment letter dated 12/07/2010: "We are nearing the completion of the process relating to the concerns you expressed in your letter. . . I apologize that it is taking a bit longer than we anticipated. We expect to respond to you in writing no later than Monday, December 27, 2010."

During a face to face interview on 12/10/2010 at 8:55 a.m., Vice President of Quality S32 indicated the hospital had not identified a grievance, as coming from Patient #3's daughter, until 11/08/2010. S32 indicted that prior to that date it was thought that Patient #3's daughter was simply making an information request (inquiry).

During a face to face interview on 12/10/2010 at 1:10 p.m., Chaplain S36 indicated he had spoken with Patient #3's daughter the week after the patient had died. S36 indicated he thought she (#3's daughter) was having a difficult time grieving the loss of her father and never identified the interaction as a grievance. S36 indicated he made no notes and did not recall the exact date of the conversation. S36 indicated Patient #3's daughter had implied that she did not trust the pathologist that was performing the autopsy on her father. S36 indicated #3's daughter had indicated she did not trust the Institution or the physician (S22) that had performed surgery on her father. S36 indicated #3's daughter implied something had happened to her father, that she knew how doctors talked with one another, and that she felt the autopsy was going to be corrupted. S36 further indicated that he works directly with the Patient Relations Department and would have communicated with them if he had ever thought his exchange with Patient #3's daughter was a grievance. Chaplain S36 indicated he saw Patient #3's daughter's inquiry as a grief response; where she felt she had to blame someone for her father's death. (Review of the hospital's electronic "Inquiry" regarding Patient #3's daughter revealed in part, "10/11/10" , "escort the family to the Pastoral Care Department, and she would have Chaplain S36 speak with the family (Patient #3's daughter) stated she spoke with Chaplain (S36) last week and she would be in agreement to speak with him again."

During a face to face interview on 12/10/2010 at 11:25 a.m., Unit Director S11 indicated she had spoken with Patient #3's daughter although she did not recall the date or time and had no documentation of the meeting. S11 indicated Patient #3's daughter believed information was being hidden from her. S11 indicated Patient #3's daughter implied that the Surgeon (S22) and the "Big Institution" were hiding things from her. S11 indicated Patient #3 seemed to be having a difficult time accepting the death of her father. S11 indicated Patient #3 would not be specific about what she felt was "hidden" .

Face to face interviews were held on 12/09/2010 at 11:00 a.m. with Surgeon S22 and on 12/10/2010 at 11:00 a.m. with the Vice President of Medical Affairs S12. Both indicated they had spoken with Patient #3's daughter (at the hospital) and attempted to answer all her questions. S22 did not recall the date/time. S12 indicated he met with the family on 11/02/2010.

During a face to face interview on 12/13/2010 at 9:05 a.m., Vice President of Quality S32 indicated that she (S32) had viewed Patient #3's complaint to Chaplain S36 the week after patient #3 died (10/11/2010) as an information request only and did not believe it to be a grievance (Patient #3's daughter had indicated to Chaplain S36 that she (daughter of #3) had believed that the hospital had done something to her father and was trying to hide it). Further S32 indicated the telephone call from Patient #3's daughter to Patient Relations on 10/27/2010 (when she voiced being unhappy with her conversation with Physician S22 and wishing to escalate her concern to the next level with the additional comment that if the hospital failed to resolve her issue, she planned on reporting her concerns to the Department of Health and Hospitals) had also not been viewed as a grievance. S32 indicated the hospital had not identified a grievance concerning Patient #3's daughter's concerns until the date of 11/08/2010. S32 further indicated that the conclusion of Patient #3's Grievance was awaiting completion of Peer Review and Root Cause Analysis. S32 indicated the hospital's goal was to have the Grievance Process completed by the end of December at which time a final letter would be mailed to Patient #3's daughter.

Based on record review and interview the hospital failed to ensure Patients and/or Patient's legal representatives had access to their clinical records within a reasonable time frame for 2 of 4 patients reviewed for processing the Release of Medical Records (#3, #R4). Findings:

Patient #3:
Review of Patient #3's Medical Record revealed the patient was admitted to the hospital on 10/05/2010 and expired in the hospital on 10/07/2010.

Review of an Authorization for Release of Confidential Information for Patient #3, signed by the patient ' s wife revealed a " receipt date " of 10/29/2010.

Review of the hospital ' s eSmartlog Request (electronic documentation of Medical Records release request) revealed information regarding Patient #3 ' s Medical Record Release Request dated 10/29/2010 at 4:17 p.m. to be processed as " No Patient Found " .

During a face to face interview on 12/10/2010 at 8:55 a.m., Vice President of Quality S32, HIM (Health Information Management) Director S9, and Release of Information Specialist S10 presented a document titled, "Timeline of Events" outlining the process for obtaining Patient #3's Medical Record as requested by his (#3's) family after the death of Patient #3 on 10/07/2010. S32 indicated Patient #3's family sent a Request for Release of Patient #3's Medical Record on 10/27/2010. S23 indicated Patient #3's family had been provided inaccurate information by Release of Information Specialist S33 on 10/29/2010 indicating there was no evidence found in the hospital's computer system that Patient #3 had ever been a patient at the hospital.

During a face to face interview on 12/10/2010 at 8:55 a.m., Release of Information Specialist S10 indicated she had received a phone call on 11/01/2010 (5 days after #3's daughter was told there was no indication that Patient #3 had ever been a patient at Ochsner Foundation Hospital) by Patient #3's family requesting information about processing the release of #3's Medical Record. S10 indicated she looked at the process request listed in the electronic system (documented by S33) and saw that the form indicated there was "no patient found". S10 indicated she informed the family there was no evidence that indicated Patient #3 had ever been treated at the hospital. S10 indicated Patient #3's family explained the dates of his admission and death. S10 indicated she did an electronic search herself and found the Patient's record. S10 indicated she informed the family that she had found the record and would process it for release. S10 indicated she sent the record to Patient #3's family the following day (11/02/2010).

During a face to face interview on 12/09/2010 at 10:05 a.m., HIM (Health Information Management) Director S9 indicated the hospital had a system in place that was to ensure there were no missed requests for Medical Records. S9 indicated any request for Medical Record Release that could not be found would be placed in a Bin for a second attempt at processing. S9 indicated Patient #3's Request had been sitting in this Bin at the time the family called again on 11/01/2010. S9 indicated it had not yet been reviewed at the second check point.
Further S9 indicated Patient #3's Medical Record had been "locked down" sometime in November for Risk Management purposes. S9 indicated this mechanism would prevent staff from other departments such as outpatient clinics from being able to view the Medical Record of the patient. S9 indicated there was no information missing from the Medical Record Request by Patient #3's daughter on 10/27/2010. S9 indicated the error had been on the part of the Information Request Worker due to her failure to search all locations where patient's admissions were stored electronically.

Patient #R4:
During a telephone interview on 12/13/2010 at 1:40 p.m., HIM Director S9 indicated a request for a copy of Patient #R4's Medical Record had been made by the patient (initial date not known). S9 indicated the initial search and the backup search (second check) had been completed on 11/04/2010 with "No Patient" found. HIM Director S9 further indicated a letter was drafted to the patient informing her that additional information would be needed because there had been no documented evidence that R4 had ever been a patient at the hospital. S9 indicated on 11/14/2010 (10 days after the second check had failed to reveal evidence of the patient's admission to the hospital), the Medical Record for Patient #R4 had been found and the error had been on the part of the hospital. S9 indicated the patient's record had been missed on the initial search and the second search of the hospital's electronic medical record logs.

During a face to face interview on 12/13/2010 at 1:50 p.m., Vice President of Quality S32 indicated there were an average of 4,820 medical record request per month at the hospital. During the same interview HIM Director S9 indicated the hospital had 4 electronic data banks where patient records could be logged (Clinic Patient Inquiry, Patient Search, Registration Patient Search, and Chart Tracking System). S9 indicated the department had thought having a second check point would ensure that all medical records were found when requested and none would be missed.

Review of the hospital policy titled, "Release of Information Paper and Electronic Documentation, #158010-39, issued 2/05" presented by the hospital as their current policy revealed in part, "4. Using the patient name and other identifiable information, obtain the OCF (Ochsner Clinic Foundation) clinic number using the RGI (patient registration) system, RGI 14 (Social Security #). 5. Write the clinic number in the upper right hand corner of the request. 6. Obtain the location of the medical record using the CTI (Chart Tracking System). 7. Log the request into the E Smart Log. 8. Retrieve the medical record and update the location in the chart tracking system to indicate the medical record is in the release of information area. . . 11. Scan/Copy the medical record documents located in the paper chart as requested per the authorization. . . 16. On the back lower corner of the authorization, write the date that the request was copied/scanned, number of pages, information scanned/copied, representative name and number. . . 19. If the requested information if copied in lieu of scanning, mail the information according to procedure."

Based on record review and interview the hospital failed to identify Quality Indicators for the purpose of monitoring the problem prone area of processing request for Medical Records. Findings:

Review of a list of Medical Record Requests that were cancelled due to inability of the hospital to find the patient identified in the request revealed 139 records for the time frame from October 1, 2010 through 12/09/2010.

During a face to face interview on 12/13/2010 at 1:50 p.m., Vice President of Quality S32 indicated the hospital processes an average of 4,820 requests per month. Further S32 indicated the search for these records must occur in four different data banks (Clinic Patient Inquiry, Patient Search, Registration Patient Search, and Chart Tracking System).

Three patients from the list of Medical Requests that were unable to be found were reviewed by HIM (Health Information Management) Director S9 at the request of the surveyors. During a telephone interview on 12/13/2010 at 1:40 p.m., HIM Director S9 indicated a request for a copy of Patient #R4's Medical Record had been made by the patient (initial date not known). S9 indicated the initial search and a backup search (second check) had been completed on 11/04/2010 with "No Patient" found. HIM Director S9 further indicated a letter was drafted to the patient informing her that additional information would be needed because there was no documented evidence that R4 had ever been a patient at the hospital. S9 indicated on 11/14/2010 (10 days after the second check had failed to reveal evidence of the patient's admission to the hospital), the Medical Record for Patient #R4 had been found and the error had been on the part of the hospital (first two searches for the patient's medical record had failed to show results). S9 indicated the patient's record had been missed on the initial search and the second search of the hospital's electronic medical record logs.

During a face to face interview on 12/13/2010 at 1:50 p.m., HIM Director S9 indicated the department had thought having a second check point would ensure that all medical records were found when requested and none would be missed. S9 further indicated she had recently re-educated her staff on doing a proper search in all 4 data banks although she indicated she did not know the date of the education and had no documentation of the education she presented. S9 further indicated she had no quality indicators for monitoring the quality of productivity in regards to searching and locating Medical Records at the request of Patient/Families/Institutions.

Review of the hospital policy titled, "Release of Information Paper and Electronic Documentation, #158010-39, issued 2/05" presented by the hospital as their current policy revealed in part, "4. Using the patient name and other identifiable information, obtain the OCF (Ochsner Clinic Foundation) clinic number using the RGI (patient registration) system, RGI 14 (Social Security #). 5. Write the clinic number in the upper right hand corner of the request. 6. Obtain the location of the medical record using the CTI (Chart Tracking System). 7. Log the request into the E Smart Log. 8. Retrieve the medical record and update the location in the chart tracking system to indicate the medical record is in the release of information area. . . 11. Scan/Copy the medical record documents located in the paper chart as requested per the authorization. . . 16. On the back lower corner of the authorization, write the date that the request was copied/scanned, number of pages, information scanned/copied, representative name and number. . . 19. If the requested information if copied in lieu of scanning, mail the information according to procedure."

Based on record review and interview the hospital failed to ensure all nurses providing care to patients were current in Cardio Pulmonary Resuscitation (CPR) as per hospital policy for 1 of 4 Registered Nurses (RN) reviewed (S17). Findings:

Review of the personnel file for RN S17 revealed her Certification as a Healthcare Provider from the American Heart Association in Cardio-Pulmonary Resuscitation and Automated Electronic Defibrillation expired on 8/2010 (2 months prior to her resignation). RN S17 continued to work in the hospital without current CPR training until the date of her resignation on 10/22/2010.

Review of the hospital policy titled, "Cardiopulmonary Resuscitation Training, #8610pc-17" presented by the hospital as their current policy revealed in part, "Ochsner Clinic Foundation requires that employees who have direct patient care responsibilities be trained and competent in cardiopulmonary resuscitation according to the Standards of American Heart Association. . . Employees must plan to attend a renewal course with an appropriate time frame for renewal and must present a current CPR card at the renewal session. . .Positions requiring CPR are listed below. This list may not be all-inclusive. . . RN (Registered Nurse). . ".

Based on record review and interview the hospital failed to ensure autopsies were released to authorized individuals for 1 of 1 released autopsies reviewed (Patient #3). Findings:

Review of Patient #3's Consent for Autopsy (2 page form) signed by the patient's (#3's) wife on 10/07/2010 (no documented time) revealed the following written information located on page 2 of the form : "Important Notice: Please do not offer a copy of the autopsy findings to the relatives. If they request a report, they must get it from the attending physician, who at his/her discretion may or may not use the autopsy protocol or list of findings furnished to him/her by the Department of Pathology. It is always better to submit such reports to the family doctor rather than to the relatives."

During a face to face interview on 12/09/2010 at 8:55 a.m., HIM (Health Information Director) S9 and Release of Information Specialist S10 indicated the autopsy report for Patient #3 had been provided to the family upon request for a copy of the Medical Record on 11/01/2010. S9 and S10 indicated Medical Records staff routinely release autopsies to the family when requested. S9 and S10 further indicated they (S9 and S10) had no awareness of the "Important Notice" listed on the consent for autopsy form that indicated relatives "must get it from the attending physician". Both S9 and S10 indicated if they had been aware of this "Important Notice" they would never have released Patient #3's Autopsy result directly to the patient's family. S9 and S10 indicated they were not aware of any policy addressing the release of autopsy reports.

During a face to face interview on 12/09/2010 at 8:55 a.m., Vice President of Quality S32 confirmed that the Autopsy Request for Patient #3 was the standard hospital consent form used in the hospital for autopsies. S32 further indicated there was no documented hospital policy or protocol to outline how autopsy reports should be processed when a patient's family member requested a copy of the patient's autopsy.

During a face to face interview on 12/09/2010 at 8:00 a.m., Contracted Pathologist S7 indicated she was the physician that performed the autopsy on Patient #3. S7 further indicated that she had not been aware of Ochsner Foundation Hospital's process for releasing autopsy reports; however, it would not be wise to provide family members with the report in the absence of an explanation from the clinician providing care to the patient at the time of his/her death. S7 indicated she(S7) had never made it her (S7) practice to speak with family members regarding the results of autopsy findings because the findings alone would not answer family members' questions and could create more confusion. S7 indicated the information discovered in an autopsy would not provide the story of the patient's history outside of the clinical picture known to the Primary Care Physician. S7 indicated it would be the attending physician that would be able to take the clinical picture in combination with the autopsy findings and outline the story of events that may have occurred in the death of a patient. S7 illustrated the point she was trying to make by referencing Patient #3. S7 indicated that during the autopsy of Patient #3, she had seen evidence of multiple abdominal surgeries. S7 indicated that the pathologist performing the autopsy would not be able to determine which surgeries were old and which were new. S7 indicated all surgery sites would look the same on an autopsy. S7 indicated the results of an autopsy would only confuse the family member if given to them by the pathologist because the data would only have meaning when combined with the clinical events as seen by the attending physician.

During a face to face interview on 12/09/2010 at 2:00 p.m., (Ochsner Foundation Hospital) Pathology Director S15 indicated that autopsy results would best be provided to family member's by the clinician that provided care to the patient. S15 indicated the pathology department would be available for consultation with the Primary Care Physician in order to provide explanations of the results, as needed. S15 confirmed that the hospital's consent for autopsies indicated the report should not be provided to relatives of the deceased. S15 indicated the consent indicated the report should be provided to the family by the Primary Care Physician. S15 indicated the purpose of having the autopsy results provided to family members by the attending physician was to ensure the report did not confuse family members. S15 indicated the Primary Care Physician/Attending Physician would be able to provide the family with the opportunity of looking at the autopsy results in conjunction with the clinical picture.

During a face to face interview on 12/09/2010 at 11:00 a.m., Surgeon S22 indicated he was the physician that performed surgery on Patient #3 two days prior to his death. S22 further indicated he had met with the patient's family for a discussion of the case although he could not recall the date of the meeting. S22 indicated Patient #3's family (daughter and wife) had called one Saturday after the Patient's death to request a meeting with him. S22 indicated Patient #3's family had been hostile towards him (S22) on the day of the patient's (#3) death and therefore he (S22) decided he (S22) should call the hospital's legal department before arranging a meeting with the family. S22 indicated he did meet with the family later that week (again unable to recall date); however, he had never seen the patient's autopsy and there had been no discussion of the autopsy.