HospitalInspections.org

Based on policy and procedure review, grievance file review, security log review and staff interviews hospital staff failed to investigate a Patient's grievance that the patient was locked in a waiting area unable to leave for 1 of 9 grievance files reviewed. (Patient #3)

The findings included:

Review of the policy "Complaints and Grievances from Patients", dated 10/09/2020, revealed "...Billing issues.... usually are not considered grievances. However, billing issues that also relate to patient service/care issues ....are considered grievances....if the review determines the is a cgrievance laim or risk to the organization, then the case is handed off to Risk Management for further handling....All further communication with the patient will be handled through the Risk Management or Claims Management Department. ..."

Review of a Grievance on 05/12/2021 for Patient #3 revealed the event occurred 08/07/2020 and the complaint was made on 02/11/2021. Review revealed "...ED NURSING....1. Patient reports she was locked in a room with three other patients and could not get out of the room. 2. Pt. stated that because of the situation of being locked in the room she had a panic attack and was adv (advised) that she would not have to pay for the EKG that she is billed for. 3. Patient reports that a chair initially used to block door open as the room is typically used for BH (behavioral) patients, but during her visit the room was for patients believed to have COVID. Patient reports once chair slipped and door closed, RN was looking for someone with a key and no one could seem to find a key to unlock the door, causing her....additional stress and panic. Patient reports that she should not have to pay....because of the continued frustration and inconvenience in regard to attempting to get this matter resolved and she may be contacting an attorney. ..." Review of the Grievance File indicated a letter was sent on to Patient #3 on 02/12/2021. On 04/14/2021, review of the grievance revealed Patient #3 requested a second review and "...also reports that she does not have 30 days to wait on a response....reports that the letter she received was a 'form' letter and she will take other action as well to have this matter resolved appropriately. Patient reports that her trauma has worsened due to events that occurred in the ED... ."

Interview on 05/12/2021 at 1500 with a Risk Manager revealed a "Risk Analysis Team" reviewed grievances whenever there was a request for compensation. If that team had questions, the Risk Manager stated, they would reach out to the Clinical Team.

Interview with RN #1, on 05/13/2021 at 1115, revealed she was the Charge Nurse on duty when the incident occurred. Interview revealed it was a very busy day. Interview revealed the ED Secretary gave her a note that a patient's spouse had called in stating his wife was locked in the waiting room. Interview revealed they looked at the tracking board and the patient was in "Care Station E". Interview revealed she picked up the phone and called public safety to open the door. Interview revealed RN #1 could not go to the room immediately so the next call was to an Assistant Manager who said she would check into it, and by the time the Assistant Manager arrived the door was already opened. Interview revealed the Assistant Manager assessed Patient #3 who said she had chest pain so an EKG was ordered. Interview revealed RN #1 did not complete an incident report and did not know if one was completed.

Interview with the Assistant Nurse Manager (ANM), on 05/13/2021 at 1245, revealed she was called about the locked door and went over there and it had already been opened. Interview revealed one of the patients was complaining of chest pain so she got an EKG. Interview revealed the patient was stressed and paniced. The ANM stated Patient #3 was the only patient with any change in condition. Interview revealed she did not think to do an incident report. Interview revealed she "felt like it was handled, she apologized and it was over."

Interview with Administrative Staff members including the President and Chief Nursing Officer, on 05/13/2021 at 1130, revealed a call was made to Public Safety at 1818 which indicated "need door unlocked right away". When Public Safety arrived to the ED the door was already opened/unlocked. Interview revealed on 02/11/2021 Patient #3 contacted Billing and stated she had been told that due to the trauma sustained she would not be billed. Interview revealed that with a financial request, the information went to the claims side and closed the ED view. The Risk Analysis Team completed the review, per interview, and because of the time lapse after the visit and because that with COVID19 the test could be considered standard of care there was not follow-up or investigation with ED leadership. Further, interview revealed, there was no documentation in the medical record of the incident and there was no incident report filed. Interview revealed the person who did the Risk Analysis work was not available for interview and leadership could not speak to why clinical staff were not contacted. Interview revealed leadership was not aware of the incident until 05/12/2021 and revealed they were not aware the space was being used as a waiting area. NC00176744, NC00173212, NC00172997, NC00172952, NC00172871, NC00172512, NC00171687, NC00169683, NC00167387, NC00165702, NC00165521