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Based on review of hospital documents and interview, it was determined the hospital failed to require the implementation of the hospital's grievance policy to include responding to the complainant in writing within 7 days after receiving the complaint, and 7 days after the resolution of the complaint for Patient #8.

Findings include:

The policy, Grievance Process Concerns of Patients and/or Families, revealed: "...Definitions...Patient/family grievance: A verbal or written concern or complaint that cannot be resolved promptly by staff/management...Grievance...If issue is not immediately resolved or the investigation will not be completed within seven days, inform the patient and/or family in writing acknowledging the receipt of the grievance and communicating an approximate timeframe for resolution...b. Direct the grievance to the appropriate management team for resolution. Once resolved, provide the patient and/or family with a written response within seven business days of resolution...."

Patient #8 presented to the emergency department (ED) on 1/14/10, at 1335, via wheelchair, after sustaining a fall. The triage documentation did not include someone accompanying the patient to the ED.

On 03/10/10, the Vice President (VP) of Administration provided a correspondence sent on 01/14/10, at 1847, from RN #12, that revealed a complaint was filed on behalf of the patient, indicating the patient was wandering in the parking lot, when a family member went to pick up the patient.

RN #12 documented that she "looked into these complaints, talking to all the nurses involved."

On 03/11/10, at 1000, the ED Director confirmed the hospital did not respond in writing to the complainant within 7 days after receiving the complaint, or 7 days after the resolution of the complaint.

Based on review of policy and procedure, medical record, and interview, it was determined the registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 1 patients (Pt. #8).

Findings include:

The policy, "Department Operating Policies:...Emergency Services," Issue Date: 3/15/07, Revision Dates: 11/06/08, 03/27/09, 12/18/09, revealed: "...All patients receiving narcotics/sedation will be discharged from the Emergency Department via wheelchair with a designated driver...."

Patient #8 presented to the ED on 1/14/10, at 1335, via wheelchair, after sustaining a fall.

The Physician's Assistant (PA) on 1/14/10, at 1651, documented: "...The patient receives Lortab one tablet p.o. (by mouth) with good improvement of (Patient #8's) symptoms...is given a prescription for fifteen Lortab and cautioned this could cause (the patient) to be sleepy, groggy, and also can cause constipation...."

A RN documented the patient received 1 tablet of Lortab on 01/14/10, at 1505, 40 minutes before the patient signed discharge instructions.

At 1545, a nurse documented: "...D/C (Discharge)...Method: Ambulatory...With whom: Taxi...Condition: Stable...."

On 3/10/10, at 10:00, a Case Manager, RN #11, confirmed the patient's nurse had called her on 1/14/10 to arrange transportation for the patient (pt). The pt. was sitting in the hall, and was talking on the telephone, and stated her daughter was coming to transport her home.

The Case Manager described the patient as "delightful," had interacted spontaneously, and didn't display memory problems or disorientation during their conversation. She stated the patient had walked with a steady gait, and she had accompanied the patient to the lobby, walking "side by side." RN #11 recalled introducing the patient to the triage nurse RN #10, had showed the patient where the restroom was located, and the driveway "loop" where her daughter would drive through to pick her up. The Case Manager left the patient in the triage waiting area.

On 3/10/10, at 1445, the triage nurse, RN #10, confirmed the patient was brought to the triage area where she was working. She recalled the patient was waiting for her ride. The patient was seated in a chair when RN #10 left the area to assist with patient care. When RN #10 returned, the patient was no longer in the triage area and she stated that she assumed the patient's ride had come for her.

On 3/9/10, at 11:00, the ED Systems Director confirmed the patient received Lortab, a narcotic. She confirmed that the patient was discharged ambulatory and the staff did not follow the policy requiring all patients who received narcotics be discharged via wheelchair to a designated driver.