HospitalInspections.org

Based on document review and staff interviews it was revealed the facility failed to follow their complaint/grievance policy. This failure was identified in one (1) of one (1) complaint/grievances reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with the Director of Risk Management and Patient Safety on 4/12/21 at 8:47 a.m. He stated when the complaint was received on 12/21/20, the complaint was the patient laid in urine. The complaint was from the next of kin for patient #1. He stated the Nurse Supervisor went and talked to the patient about her care, the patient had a Foley so she could not have been wet. He stated the issue was resolved at the time it was received. The Nurse Supervisor talked to him after talking to the patient. The patient was alert and oriented and had capacity. The next of kin, who made the complaint, was not the Medical Power of Attorney (MPOA) or surrogate at that time, so no follow up was conducted. The next of kin was made surrogate on 1/13/21.

2. A review of the complaint/grievance policy titled "Patient Complaints and Grievances" stated in part: "A complaint is considered resolved when the patient is satisfied with the actions taken on his/her behalf. Grievance: A formal or informal written or verbal (including by telephone) complaint that is made to the hospital by the patient or the patient's legal representative regarding patient care, ... abuse, neglect, patient harm or hospital compliance with CMS {Centers for Medicare & Medicaid Services} Hospital Conditions of Participation. Requirements for investigation, resolution and timely written response apply: PROCEDURE:
A. .....
B. When a complaint is received by any RGH {Raleigh General Hospital} staff member, the staff member present is to:
1. Offer an apology on behalf of RGH for failing to meet the expectations of the patient or their representative(s).
2. Attempt to resolve the complaint immediately if possible. If unable to do so, the staff present is to request the presence of the department director. In the absence of the department director, the house supervisor or other authorized hospital representative will be contacted to address the complaint.
3. Upon arrival, the department director, house supervisor, or other authorized representative will again apologize on behalf of the hospital and attempt to resolve the complaint immediately.
4. If unable to resolve, the staff member receiving the concern will notify the patient that the complaint will be referred to the Grievance committee for investigation, resolution, and follow-up.
5. Calls received by staff members from patients or their representatives wishing to voice a concern will be given to the department director, keeping the individual on the phone until the department director is located before transferring the call. In the absence of the department director, the call will be given to the house supervisor or other authorized representative."

3. A telephone interview was conducted with the Director of 4 North on 4/13/21 at 10:07 a.m. The Director of Risk Management and Patient Safety was also on the call. When asked about the complaint from the next of kin, she stated she never received a complaint like that before. She received a call from someone from Medicare about the complaint and was informed to call the next of kin. She stated she received the call on 12/23/20. She stated she talked to the patient and the next of kin later that day about her having the sensation of urinating due to she had a Foley. She noted the patient wasn't wet. She told the patient they would do more frequent checks on her due to she was very anxious. She stated the patient was alert and oriented when she spoke to her. She was not aware of a complaint about care on 12/21/20. During the interview, the Director of Risk Management and Patient Safety concurred the Director of 4 North addressed a complaint received on 12/23/20, not 12/21/20.

Based on review of the medical record for patient #1 it was revealed the facility failed to provide an appropriate discharge planning evaluation for post-hospital care before discharge to avoid unnecessary delays in discharge. This failure was identified in one (1) of eight (8) discharge records reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted to the facility on 12/18/21. Patient #1 was discharged to the rehab facility on 1/8/21. There was no documentation in the medical record from case management about arrangements for a wound vac and a Bilevel Positive Airway Pressure (BIPAP) prior to discharge. Patient #1 was readmitted back to the Emergency Department (ED) on 1/8/21 and the ED physician stated in part, "The patient was brought back to the ED due to a BIPAP not being available at the rehab facility for the patient to use. The patient is to stay here at the hospital until one can be made available at the rehab facility. Case management was notified."

2. An interview was conducted with the Director of Case Management on 4/13/21 at 12:10 p.m. When asked about the discharge of patient #1, she stated the patient was given a choice for which nursing home she wanted to go to, then the referral was made and accepted. She stated once the referral is made then the liaison (the accepting facility staff) for admission ensures the patient has all the appropriate equipment. The liaison is at the facility and arranging everything. When asked if they arrange for any equipment prior to discharge or if the liaison does all the arrangements for equipment, she stated once the referral is made the liaison does the rest.

3. A review of the policy titled "Discharge Planning," review date 11/2017, stated in part: "Screening will include assessment of the patient's psychosocial and discharge planning needs ... All patients will be re-evaluated as needed for a change in condition or changes in the discharge plan while in the facility to ensure an appropriate and timely discharge plan ... Discharge needs (i.e., home health, DME {durable medical equipment}, community services) will be arranged by the case manager etc. ...