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Based on interview, document review and medical record reviews, the facility failed to ensure that it provided a timely resolution to a patient grievance for two (Patient #1 and Patient #3) of four patients reviewed for complaint and grievances. The failure to ensure timely follow up and resolution with complaints, placed the facility complaint and grievance process at risk to allow systemic failure in patient care to remain uncorrected, limited the patient's reliability on the grievance process, and placed the quality of patient care delivery at risk of not having identified concerns addressed.

The findings include:


1) Patient #1 was a 19 year-old male who was brought to the hospital by his mother on 6/19/2021 with a documented initial screening at 9:45 PM. Patient #1 medical record was reviewed and it was documented Patient #1 was seen by a Provider on 6/19/2021 at 10:43 PM. The mother and Patient #1 left the facility based on the reported experience that Patient #1 was not provided care. The reported lack of care included, the mother stated, the doctor (Physician #1) did not provide a pain medication intervention for Patient #1; and the facility staff did not provide a timely diagnostic MRI the physician said was ordered. It was confirmed that Patient #1 left the facility against medical advice (AMA) with the last documented intervention on 6/20/2021 at 3:10 AM by Employee A, RN.

On 6/28/2021, it was documented by the facility that Patient #1's mother (patient representative) who was present at the time of the incident on 6/19/21 to 6/20/2021, contacted the facility's Patient Relations line. During a telephone interview with Patient #1's mother, she confirmed she filed a formal complaint/grievance over the phone. The mother's expectation was that the facility was going to look into the allegation and call her back. Based on a review of the complaint initial intake dated 6/28/2021, the documented intervention by Employee B, Employee Relations Specialist (ERS), Patient #1 understood the grievance process; however, the facility failed to respond to the mother of Patient #1 about the complaint created for the reported incident related to the hospital visit dated 6/19/21 to 6/20/2021 for Patient #1.


A telephone interview was conducted with the mother of Patient #1 on 02/05/2022 at 10:43 AM. The mother confirmed she was her son's patient advocate and filed a complaint with the facility about her son's experience on 06/19/21 to 6/20/2021. She confirmed although she chose to leave the facility on her own, it was because she was not happy with the treatment her son received at the facility. She filed a complaint about the care. During the call she confirmed the facility never provided her with a letter and she never heard from the facility. She said, "So I just forgot about it because I did not think I was going to hear from anyone by this time."

On 02/10/2022 at 12:30 PM, a telephone interview was conducted with the mother of Patient #1 and she stated when she called the customer relation's number, "They told me they would call back; whoever was contacted would take notes, look at the files and call me back." She confirmed that she reached out to customer relations two times and was told someone would call her and she never received a call.

On 02/10/2022 at 12:39 PM, Patient #1's mother called back and confirmed by voice message the following information, "I filed a formal grievance, there is a patient's relations place where they have a phone number, what I did was the process for a formal grievance on the patient relation's department website and the number was 386-425-4874. So I called this place, patient relations. I did file a formal grievance, they were supposed to call me back and they did not."

A review of the facility's complaint intake form was conducted with Employee C, Registered Nurse, Emergency Department Manager (RN EDM) on 02/09/2022 at 11:10 AM. She confirmed the response from Physician B, Medical Director (Emergency Department) was dated 8/11/2021 at 10:52 AM for an event/complaint reported about the visit for Patient #1 dated 6/19/21 to 6/20/2021.

An interview was conducted with Employee C, RN EDM on 2/09/2022 at 11:30 AM. She confirmed the reviewed Complaint entered for Patient #1 was initiated by Employee B, Patient Relations/Risk Management during intake phone conversation that occurred on 6/28/2021. It was confirmed the mother of Patient #1 called the patient relation's staff and documented the reviewed note, "Contacted patient relations with concerns related to physician behavior. Mother stated Patient #1 was in distress with his symptoms. Provider examined the patient and informed the mother that pain medication and an MRI would be ordered.

An interview was conducted with Physician #2, Emergency Department Medical Director (EDMD) on 02/09/2022 at 11:47. He reviewed the complaint event related to the allegation of lack of care for Patient #1. Confirmed no reason to delay pain medication, confirmed there was a delay in getting an MRI completed for Patient #1; however, when the MRI was authorized by the Radiologist, Patient #1 and the mother left the facility Against Medical Advice (AMA). He confirmed his response to the complaint was documented 8/11/2021 and he did not contact the complainant.

An interview was conducted with Employee B, Patient Relations Specialist on 2/10/2022 at 8:54 AM. She confirmed Physician #3 reviewed the complaint and companion Event submitted for Patient #1 who responded on 6/25/2021 at 11:41 AM through the complaint record keeping. Physician #3 confirmed the department was informed of the occurrence in Radiology. Reply was-we have policies in regard to MRI. They are for emergency only. That being said, it seemed like the Radiologist did approve the emergency study. Employee B, Patient Relations Specialist stated that the complaint/event was closed on 6/28/2021 at 12:49 PM.

A review of the facility's Policy Title, "Patient Complaints/Grievances Policy" Patient relations specialist revised last dated 11/21. Purpose indicated to establish a process for prompt resolution of all patient grievances and complaints. To provide a process for receiving, investigating, and assuring adequate follow-up of complaints and grievances received from the patient or patient representative. Defined "patient grievance" as a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding care (when the complaint is not resolved at the time of the complaint by staff present). Subsection b) If patient care complaint cannot be resolved at the time of the complaint by staff present...requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. Subsection f) Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care. Under subsection h) Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply. Documented goal for resolving (Responding to non-urgent patient grievances is seven (7) days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital informs the patient or patient representative that the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within (15) days. [Submitted Policy]

No information was provided that the facility's policy titled, "Patient Complaints/Grievances Policy" was followed completely for Patient #1's representative complaint, which included appropriate response to the complainant.

2.) A review of the medical record for Patient #3 documented the patient visited the facility on 6/18/2021 at 4:10 PM. The visit included interventions that resulted in a complaint being filed with the facility patient relations system on 6/22/2021. During a visit to the facility the patient expressed that nursing staff attempted too many intravenous (IV) site attempts, even after Patient #3 was reported by the family member, had requested the staff to stop.


A review was conducted of a complaint submitted by the family/surrogate of Patient #3 dated 6/22/2021. The complaint was documented closed out by Employee D, Quality Improvement Coordinator Radiology (QICR) dated 6/25/2021 at 12:04 PM with a note that read, please share with the appropriate person. The information reviewed indicated that Employee D, QICR discovered that the patient complaint was related to care received when staff attempted multiple IV site attempts (5) times; documented in the complaint allegation reviewed by Employee D, QICR, even once Patient #3 requested them to stop.

An interview was conducted with Employee C, Registered Nurse Emergency Department Manager (RN EDM) on 02/09/2022 at 11:21 AM. She reviewed the submitted complaint for Patient #3 dated 6/22/2021 and confirmed that she did not take any action related to the comments about too many IV sticks to Patient #3. She stated that she could have provided an inservice to staff after the event, if she knew about it. The staff was only supposed to attempt 2 times an IV site by two different staff. She confirmed she closed out her review and never received the complaint task back to review further.

An interview was conducted with the Director of Risk Management on 2/09/2022 at 2:35 PM. The Risk Management Director confirmed that instead of Employee D, QICR typing a comment in the response, Employee D, QICR was supposed to task the complaint back to the Emergency Department Manager (Employee C, RN ED Manager) to follow up.


An interview was conducted on 2/10/2022 at 9:39 AM with Employee D, QICR. He confirmed a newly identified concern related to the complaint report reviewed for Patient #3 after he called the Patient on 6/24/2021 at 9:10 AM. He documented he would refer this to the appropriate persons. He confirmed he was supposed to forward the task to the Emergency Department and did not.

A review of the facility's policy documented as IV catheter Insertion indicated the best practices are followed when providing intravenous therapy: "Each patient should have a maximum of no more than 2 attempts by 2 different providers (total of 4 attempts) before calling the physician or Vascular Access team for assistance. If it is noted to be a difficult insertion prior to attempting placement a second time or by a second person, please initiate a consult. [Policy obtained]

Based on interview, document review and medical record review, the facility failed to ensure that it provided a patient with written notice of it's decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for 1 (Patient #1) of 4 patient complaints sampled.

The findings include:

1) Patient #1 was a 19 year-old male who was brought to the hospital by his mother on 6/19/2021 with a documented initial screening at 9:45 PM. Patient #1 medical record reviewed and it was documented Patient #1 was seen by the Provider on 6/19/2021 at 10:43 PM. The mother and Patient #1 left the facility based on the reported experience that Patient #1 was not provided care. The reported lack of care included, the mother stated, the doctor (Physician #1) did not provide a pain medication intervention for Patient #1; and the facility staff did not provide a timely diagnostic MRI the physician said was ordered. It was confirmed that Patient #1 left the facility against medical advice (AMA) with the last documented intervention on 6/20/2021 at 3:10 AM by Employee A, RN. On 6/28/2021, it was documented by the facility that Patient #1's mother (patient representative) who was present at the time of the incident on 6/19/2021 to 6/20/2021, contacted the facility Patient Relation's line. During a telephone interview with Patient #1's mother, she confirmed she filed a formal complaint/grievance over the phone. The mother's expectation was that the facility was going to look into the allegation and call her back. Based on a review of the complaint initial intake dated 6/28/2021, the documented intervention by Employee B, Employee Relations Specialist (ERS), Patient #1 understood the grievance process; however, the facility failed to respond to the mother of Patient #1 about the complaint created for the reported incident related to the hospital visit dated 6/19 to 6/20/2021 for Patient #1.

A telephone interview was conducted with the mother of Patient #1 on 02/05/2022 at 10:43 AM. The mother confirmed she was her son's patient advocate and filed a complaint with the facility about her son's experience on 06/19/2021 to 6/20/2021. She confirmed although she chose to leave the facility on her own, it was because she was not happy with the treatment her son received at the facility. She filed a complaint about the care. During the call she confirmed the facility never provided her with a letter and she never heard from the facility. She said, "So I just forgot about it because I did not think I was going to hear from anyone by this time."

On 02/10/2022 at 12:30 PM, a telephone interview was conducted with the mother of Patient #1 and she stated when she called the customer relation's number, "They told me they would call back; whoever was contacted would take notes, look at the files and call me back." She confirmed that she reached out to customer relations two times and was told someone would call her and she never received a call.


On 02/10/2022 at 12:39 PM, Patient #1's mother called back and confirmed by voice message the following information, "I filed a formal grievance, there is a patient relation's place where they have a phone number; what I did was, I did the process for a formal grievance on the patient relation's department website and the number was 386-425-4874. So I called this place, patient relations. I did file a formal grievance, they were supposed to call me back and they did not."

A review of the facility's complaint intake form was conducted with Employee C, Registered Nurse, Emergency Department Manager (RN EDM) on 02/09/2022 at 11:10 AM. She confirmed the response from Physician B, Medical Director (Emergency Department) was dated 8/11/2021 at 10:52 AM for an event/complaint reported about the visit for Patient #1 dated 6/19 to 6/20/2021.

An interview was conducted with Employee C, RN EDM on 2/09/2022 at 11:30 AM. She confirmed the reviewed Complaint entered for Patient #1 was initiated by Employee B, Patient Relation's/Risk Management during intake phone conversation that occurred on 6/28/2021. It was confirmed the mother of Patient #1 called the patient relations' staff and documented the reviewed note, "Contacted patient relations with concerns related to physician behavior. Mother stated Patient #1 was in distress with his symptoms. Provider examined the patient and informed the mother that pain medication and an MRI would be ordered.

An interview was conducted with Physician #2, Emergency Department Medical Director (EDMD) on 02/09/2022 at 11:47. He reviewed the complaint event related to the allegation of lack of care for Patient #1. Confirmed no reason to delay pain medication, confirmed there was a delay in getting an MRI completed for Patient #1; however, when the MRI was authorized by the Radiologist, Patient #1 and the mother left the facility Against Medical Advice (AMA). He confirmed his response to the complaint was documented 8/11/2021 and he did not contact the complainant.

An interview was conducted with Employee B, Patient Relations Specialist on 2/10/2022 at 8:54 AM. She confirmed Physician #3 reviewed the complaint and companion Event submitted for Patient #1 who responded on 6/25/2021 at 11:41 AM through the complaint record keeping. Physician #3 confirmed the department was informed of the occurrence in Radiology. Reply was-we have policies in regard to MRI. They are for emergency only. That being said, it seemed like the Radiologist did approve the emergency study. Employee B, Patient Relations Specialist stated that the complaint/event was closed on 6/28/2021 at 12:49 PM.


A review of the facility Policy Title "Patient Complaints/Grievances Policy" Patient relations specialist revised last dated 11/21. Purpose indicated to establish a process for prompt resolution of all patient grievances and complaints. To provide a process for receiving, investigating, and assuring adequate follow-up of complaints and grievances received from the patient or patient representative. Defined "patient grievance" as a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding care (when the complaint is not resolved at the time of the complaint by staff present). Subsection b) If patient care complaint cannot be resolved at the time of the complaint by staff present...requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. Subsection f) Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care. Under subsection h) Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply. Documented goal for resolving (Responding to non-urgent patient grievances is seven (7) days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital informs the patient or patient representative that the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within (15) days. [Submitted Policy]

No information was provided that the facility policy titled "Patient Complaints/Grievances Policy" was followed completely for Patient #1's representative complaint, which included appropriate response to the complainant.