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Based on interview and record review the facility failed to follow its grievance procedure when it failed to inform the patient of the grievance results; the facility failed to convene a grievance committee to review the complaint; and the facility did not incorporate the results of the grievance into the facility's Performance Improvement program.

Findings Included:

Review of the facility provided policy PATIENT COMPLAINT AND GRIEVANCE RESOLUTION PROCESS (policy change 2/28/2013) and (reviewed on 1/22/2015) reflected:

PROCEDURE: The Board of Directors has delegated the Grievance Committee (an ad hoc committee consisting of members defined by Administration as appropriate to the grievance type. The Committee must consist of more than one person and may include members of Administration, Physician Representative, Patient Advocate, risk Management and appropriate department managers. The committee is responsible for reviewing and resolving grievances) to act on its behalf to resolve grievances.
D. The Patient Satisfaction Director document the investigation and resolution process of all patient grievances through Star.
F. A final written response from the Director of Patient satisfaction and is mailed or hand delivered to the patient after the grievance is resolved. The written response includes:
1. The hospital's decision
2. The name of the hospital contact person.
3. The steps taken on behalf of the reporting party to investigate the grievance.
4. The result of the grievance process.
5. The date of completion.
G. The grievance is resolved when the patient is satisfied with the action taken and/or outcome of the investigation.
H. The Performance Improvement committee reviews all grievances and evaluates for trends to use in performance improvement/education.

Review of the facility provided letter to the complainant, dated April 24, 2015, reflected one attempt by the facility to contact the complainant. The letter reflected Rest assured the Medical Director; MD has reviewed your chart, and made his recommendations for moving forward. Staff #17, the clinical Emergency Department Director has visited with the staff responsible for the decisions made in your case.

The facility did not provide evidence the grievance had been resolved as evidenced by the patient being satisfied with the actions taken. The facility did not present the grievance to a Grievance Committee as stated in the facility policy.

During an interview on 12/21/15 in the conference room in the afternoon, Staff #16, the Director of Risk Management stated the complaints go to the responsible department head and they did not go to a Grievance Committee. Staff #16 was asked for evidence the Grievances are reviewed by the Performance Improvement Committee; she was unable to provide specific documentation.

Based on observation, interview and record review the facility failed to provide care in a safe setting when (1)one out of (20) patient charts reviewed for presentation to the Emergency Room with a complaint of chest pain, did not recieve a diagnostic EKG , (electrocardiogram)the process of recording the electrical activity of the heart over a period to rule out a cardiac emergency, in a timely manner. (patient #1)

Findings included:

Review of the facility provided policy CHEST PAIN: GUIDELINES FOR INITIAL PATIENT MANAGEMENT (Bi-annual review and template policy change 4/15/2013) and (reviewed on 3/31/2015) reflected:
POLICY:
Outcome and Process Standards for Initial Management of Patients Presenting to the emergency Department (ED) with Chest Pain
PROCEDURE:
I. Nursing Assessment
A. Patient's description and location/radiation of pain, numeric pain rating scale
B. Duration of pain
C. Any factors which increase/decrease the intensity of pain
D. Description of skin color
E. Respiratory status: rate, depth, pattern, shortness-of breath, lung sounds
II. Nursing team interventions
A. Disrobe patient have patient don a gown.
B. Place patient in position of comfort
C. Obtain 12-lead EKG within 5 minutes of ED arrival
D. Initiate continuous cardiac monitoring, including O2 saturation
E. Notify ED physician of 12-lead EKG, patient status, and priority status
H. Obtain cardiac profile (CBC, CMP, Mg++, CK, CK-MB, Troponin I, PT/APTT, TSH, Lipid Panel) and other laboratory studies as ordered per chest pain protocol

Review of Patient #1's Consent for Treatment form dated 3/31/15 at 1:45 p.m. reflected Patient #1 completed, Explain your symptoms? as Chest Pain, Back Pain, Very Weak, throwing up, diarrhea

Review of Patient #1s Nurses notes dated 3/31/15 at 2:00 p.m. reflected a 42 year old male presenting to the Emergency Department with a history of High Cholesterol, Hypertension and Anxiety.
- 2:06 p.m. Triage Assessment reflected Musculoskeletal: Reports pain in back and chest since this am. Pain is 6 out of 10 on a pain scale.
- 2:07 p.m. Vital signs reflected an elevated heartrate of 112 beats per minute and a low grade fever of 100.5 degrees Fahrenheit.
- 3:30 p.m. Reassessment: Patient appears in no apparent distress at this time. Patient states symptoms have not improved. Reports unable to pin point which complaint would be worse complaint of abdominal pain diffuse with nausea, vomiting, diarrhea, chest pain over the left breast and axillary area 2nd- 3rd intercostal (tightness).

The notes did not reflect the nurse informing the physician of the complaint of chest pain or the abnormal vital signs.
Review of Patient #1's Physician documentation dated 3/31/15 reflected:
At 4:47 p.m. cardiovascular: Positive for chest pain, of the chest.

Review of Patient #1's EKG dated 3/31/15 was completed at 4:33 p.m. and signed as read by the physician at 4:37 p.m.

During an interview on 12/21/15 at 12:30 p.m. in the conference room, Staff #17, ED Director stated, "We do 12 lead EKGs within 5 minutes on all patients presenting with chest pain. We are a Chest Pain Center." "All EKGs are read by a physician." Staff #17 confirmed the findings.

Based on interview and record review the facility failed to maintain and demonstrate detailed evidence of its Quality Assurance program.

Findings Included:

Review of the facility provided policy PATIENT COMPLAINT AND GRIEVANCE RESOLUTION PROCESS (policy change 2/28/2013) and (reviewed on 1/22/2015) reflected:

PROCEDURE: The Board of Directors has delegated the Grievance Committee (an ad hoc committee consisting of members defined by Administration as appropriate to the grievance type. The Committee must consist of more than one person and may include members of Administration, Physician Representative, Patient Advocate, risk Management and appropriate department managers. The committee is responsible for reviewing and resolving grievances) to act on its behalf to resolve grievances.
D. The Patient Satisfaction Director document the investigation and resolution process of all patient grievances through Star.
F. A final written response from the Director of Patient satisfaction and is mailed or hand delivered to the patient after the grievance is resolved. The written response includes:
1. The hospital's decision
2. The name of the hospital contact person.
3. The steps taken on behalf of the reporting party to investigate the grievance.
4. The result of the grievance process.
5. The date of completion.
G. The grievance is resolved when the patient is satisfied with the action taken and/or outcome of the investigation.
H. The Performance Improvement committee reviews all grievances and evaluates for trends to use in performance improvement/education.

Review of the facility provided letter to the complainant, dated April 24, 2015, reflected one attempt by the facility to contact the complainant. The letter reflected Rest assured the Medical Director; MD has reviewed your chart, and made his recommendations for moving forward. Staff #17, the clinical Emergency Department Director has visited with the staff responsible for the decisions made in your case.

The facility did not provide evidence the grievance had been resolved as evidenced by the patient being satisfied with the actions taken. The facility did not present the grievance to a Grievance Committee as stated in the facility policy.

During an interview on 12/21/15 in the conference room in the afternoon, Staff #16, the Director of Risk Management stated the complaints go to the responsible department head and they did not go to a Grievance Committee. Staff #16 was asked for evidence the Grievances are reviewed by the Performance Improvement Committee; she was unable to provide specific documentation.

Based on interview and record review the facility's Director of Nursing failed to supervise the operation of nursing services when (1) one of (20) patients patient charts reviewed for presentation to the Emergency Room with a complaint of chest pain, did not receive a diagnostic EKG, (electrocardiogram) the process of recording the electrical activity of the heart over a period to rule out a cardiac emergency, in a timely manner. (Patient #1)

Findings Included:

Review of the facility provided policy CHEST PAIN: GUIDELINES FOR INITIAL PATIENT MANAGEMENT (Bi-annual review and template policy change 4/15/2013) and (reviewed on 3/31/2015) reflected:
POLICY:
Outcome and Process Standards for Initial Management of Patients Presenting to the emergency Department (ED) with Chest Pain
PROCEDURE:
I. Nursing Assessment
A. Patient's description and location/radiation of pain, numeric pain rating scale
B. Duration of pain
C. Any factors which increase/decrease the intensity of pain
D. Description of skin color
E. Respiratory status: rate, depth, pattern, shortness-of breath, lung sounds
II. Nursing team interventions
A. Disrobe patient have patient don a gown.
B. Place patient in position of comfort
C. Obtain 12-lead EKG within 5 minutes of ED arrival
D. Initiate continuous cardiac monitoring, including O2 saturation
E. Notify ED physician of 12-lead EKG, patient status, and priority status
H. Obtain cardiac profile (CBC, CMP, Mg++, CK, CK-MB, Troponin I, PT/APTT, TSH, Lipid Panel) and other laboratory studies as ordered per chest pain protocol

Review of Patient #1's Consent for Treatment form dated 3/31/15 at 1:45 p.m. reflected Patient #1 completed, explain your symptoms? As Chest Pain, Back Pain, Very Weak, throwing up, diarrhea

Review of Patient #1s Nurses notes dated 3/31/15 at 2:00 p.m. reflected a 42 year old male presenting to the Emergency Department with a history of High Cholesterol, Hypertension and Anxiety.

- 2:06 p.m. Triage Assessment reflected Musculoskeletal: Reports pain in back and chest since this am. Pain is 6 out of 10 on a pain scale.
- 2:07 p.m. Vital signs reflected an elevated heartrate of 112 beats per minute and a low grade fever of 100.5 degrees Fahrenheit.
- 3:30 p.m. Reassessment: Patient appears in no apparent distress at this time. Patient states symptoms have not improved. Reports unable to pin point which complaint would be worse complaint of abdominal pain diffuse with nausea, vomiting, diarrhea, chest pain over the left breast and axillary area 2nd- 3rd intercostal (tightness).

The notes did not reflect the nurse informing the physician of the complaint of chest pain or the abnormal vital signs.

Review of Patient #1's Physician documentation dated 3/31/15 reflected:
At 4:47 p.m. cardiovascular: Positive for chest pain, of the chest.

Review of Patient #1's EKG dated 3/31/15 was completed at 4:33 p.m. and signed as read by the physician at 4:37 p.m.

During an interview on 12/21/15 at 12:30 p.m. in the conference room, Staff #17, ED Director stated, "We do 12 lead EKGs within 5 minutes on all patients presenting with chest pain. We are a Chest Pain Center." Staff #17 confirmed the nurse in the Triage area did not follow the procedure for chest pain. Staff #17 stated she had reviewed Patient #1's chart and did not notice the two hour delay in the EKG, she was focused on the gastrointestinal complaint. Staff #17 confirmed the findings.