HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (Pt. #5) patients' grievances reviewed, the Hospital failed to ensure that a patient grievance was resolved as required.

Findings include:

1. The Hospital's policy titled, "Patient Complaint and Grievance Management" (revised 7/31/19), was reviewed and required, "...C. Each complaint/grievance is addressed, and an attempt made to resolve the issue... D. Complaints/grievances reported directly to the Patient Relations Department from a patient... referred directly to the appropriate department leader for resolution... E. Patient Relations will determine... grievance level... will inform the involved department leader of any required steps to resolving the grievance level issues..."

2. The clinical record for Pt #5 was reviewed on 5/25/2021. Pt #5 presented to the Hospital on 2/25/2021 for an elective same day surgical procedure, hysteroscopy myomectomy (HSC MMY-surgical procedure to remove uterine fibroids). Pt. #5 was discharged to home on 2/25/2021 at 2:45 PM. Pt. #5 returned to the Emergency Room on 2/25/2021 at 6:02 PM with chief complaint of vaginal bleeding.

4. On 05/25/2021 at approximately 1:00 PM, the Hospital's Event/Incident Log dated 11/2020 - 05/2021 was reviewed. The log listed an incident event (#276711 entered 3/8/2021) for Pt. #5. However, the Hospital was not able to provide documentation that the incident was investigated and follow up with (Pt. #5) was conducted, and that actions and a timely closure of incident occurred.

5. On 5/25/2021 at approximately 1:05 PM, the Hospital provided an email dated 3/2/2021 at 11:58 AM, and included, "From: (name of Pt. #5)... To: Patient Relations... I would like to file a formal complaint..."

6. On 5/26/2021 at approximately 10:26 AM, an interview was conducted with the Manager of Patient Relations (E #17). E #17 stated, "This particular incident was reported via email by the patient (Pt. #5) on 3/5/2021. However through human error it was missed. Once the email was received, a Patient Relations representative should have been assigned and the patient should have been contacted for more information. The case should have been promptly investigated. As of this morning we have initiated an audit of the case so that proper actions are taken."

Based on document review and interview, it was determined that 1 of 7 patient's (Pt. #5) clinical records reviewed for discharge education of patient's post-operative care, the Hospital failed to ensure care was supervised and evaluated by a registered nurse.

Findings include:

1. The Clinical Nurse Position Specification (dated 7/6/2014) was reviewed and required, "...Develops and implements individualized education plans for patients and families using suitable instructional materials..."

2. The clinical record for Pt. #5 was reviewed on 5/25/2021. Pt. #5 presented to the Hospital on 2/25/2021 for an elective same day surgical procedure: hysteroscopy myomectomy (surgical procedure to remove uterine fibroids). Pt. #5 was discharged to home on 2/25/2021 at 2:45 PM.

Pt. #5's After Visit Summary (AVS) dated 2/26/21 at 3:36 PM, included, "Patient Instructions: You were seen for ... Preeclampsia (dangerous condition of high blood pressure during pregnancy) Information ... Risks to you: Seizures; Stroke ... Upcoming Scheduled Appointments: April 5, Post OP (post-operative) OBGYN (name of MD #1) ..." The (AVS) did not include proper diagnosis and education for reason that Pt. #5 was hospitalized for.

Pt. #5 returned to the Emergency Room on 2/25/2021 at 6:02 PM with chief complaint of vaginal bleeding. Pt. #5 required to have a second surgical procedure to control the vaginal bleeding not for pre-eclampsia.

3. On 5/26/2021 at approximately 11:30 AM, an interview was conducted with a Physician (MD #1). (Pt. #5) was not seen for preeclampsia, she was seen to control bleeding from previous surgery.

4. On 5/27/2021 at approximately 1:30 PM, an interview was conducted with a RN (E #36) from PACU (Post Anesthesia Care Unit). E #36 stated that when a patient is being discharged, the nurse will print discharge instructions and review instructions with the patient. E #36 demonstrated how staff access their patient's electronic clinical record, they enter the reason, diagnosis, or procedure for which the patient was treated. The computer will then generate specific instructions to provide the patient. E #36 stated that it is possible to type in incorrect diagnosis or procedure.