HospitalInspections.org

Based on clinical record review, phone interviews, policy and procedure, personnel staff interview, and statements from hospital employees, the hospital failed to ensure that one (1) of (1) patient's grievance was promptly resolved and failed to inform the patient's (Patient #1) power of attorney whom to contact to file a grievance.

Findings Include:

Review of Patient #1's clinical record revealed she was admitted to (facility's name) Hospital on 8/06/10 for treatment of Pulmonary Fibrosis. The patient appointed her son as Power of Attorney (POA) for her health care.

The only documentation found in the patient's chart regarding the patient's POA requesting a change of physicians was found in the 08/09/10 "Progress Note" dictated by Physician #1. The physician documented, "She and the family had requested that (Physician #3) become her physician while she is hospitalized and he denied this request ....."

On 11/04/10 at 11:00 a.m., a telephone interview with Patient #1's POA/son was conducted. The POA stated his mother (Patient #1) was a patient in the hospital on 8/06, 8/07, 8/08, 8/09, and 8/10/2010 and that every day he faxed the 3rd Floor Nurse's Station and the administrator's office at the hospital a written statement to have (Physician #1) not see his mother again. He stated that he asked every nurse to have the attending physician replaced by another physician. He stated that the nurses, doctors, and hospital administration failed to talk to him about this concern and he was denied at every request he made.

On 11/04/10 at 12:30 p.m. the Director of Nurses (DON) was asked to review Patient #1's clinical record for her hospital stay from 8/06-8/10/10. The DON confirmed that the only documentation he/she could find regarding the request that Patient #1's POA made to change her physician was in Physician #1's progress note dated 8/09/10.


Review of the hospital's written policy on "Quality Assurance Cordinator" revealed, "I. Definition: A Registered Nurse who coordinates the activities of the hospital-wide quality assurance of patient care. II. Duties and Responsibilities - section K. Investigate all incidents, accidents, or occurrences that may result in liability to the hospital."

Review of the hospital's "Patient Admission Information Packet", given to each new patient when admitted to the facility, revealed:
"Patients Rights:
The patient has a right to receive considerate and respectful care by competent personnel.
The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure .....
The patient has the right to refuse treatment to the extent permitted by law and to be informed of medical consequences of this action.
The patient has the right to formulate advance directives & appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by the law.
"Advance Directives And You" - "What Rights Do I Have":
You have the right to give instructions about your own health-care.
You have the right to name someone else to make health-care decisions for you.
You have the right to be informed of your treatment options and must agree to be treated."

On 11/04/10 at 2:00 p.m. an interview with the DON revealed that on 8/09/10 he was aware that the POA had a complaint and had asked for Physician #1 to be replaced by another physician. The DON revealed that on 8/09/10 at about 12:00 noon he was on his way to the 3rd Floor to speak to Patient #1 POA about the complaint when he was stopped by Physician #1. The DON stated, "(Physician #1) told me that he had talked with (Patient #1's POA) and everything was OK." Physician #1 told the DON, "I took care of the problem so you do not need to talk with them." The DON stated that he did not look into the complaint any further and did not see the 08/10/10 faxed written complaint sent by the POA concerning his complaint about the hospital not addressing his requests for his mother to have another physician. The DON could not confirm any follow up or documentation of this event.

On 11/04/10 at 4:30 p.m. the Assistant DON/Risk Manager confirmed that he/she was given a copy of a complaint on 8/11/10 that was faxed to the Administrative Secretary on 8/10/10 requesting that Patient #1 be assigned another physician. The ADON/Risk Manager stated that because the patient was already discharged he/she did not do anything about the complaint. He/she could not confirm any follow up or documentation of this event.

On 11/05/10 at 9:00 a.m. an interview with Registered Nurse (RN) #1 revealed that she took care of Patient #1 on the evening shift 8/06, 8/07, and 8/08/2010. RN#1 revealed that she was given a fax message from the day shift to give to Physician #1 on his a.m. rounds and that she did give the fax to Physician #1 on 8/09/10.

Review of a written statement from RN #2 revealed: "My name is (RN#2). I took care of (Patient #1) on 8/06, 8/07, 8/08. (Patient #1's POA) voiced his concern to me on Friday Aug. 6 about how the ER doctor (Physician #2) informed him that his mother had pneumonia last night and how the doctor today (Physician #1) came in and stopped the antibiotics and said that she does not have pneumonia. (The POA) said he just did not understand. (POA) seemed aggravated but stated nothing else. I cannot remember what day it was, but either 8/06, 8/07, 8/08, I was standing at our fax machine and I remember something that said (Patient #1) investigation at shift change and the night nurse who was assuming care of pt. (patient) got the fax and was called to the pt's room. I did not see what the fax said."

Review of Physician #1's statement revealed, "(Patient #1) was admitted 8/6/2010 and discharged 8/10/2010. The patient's son asked to be discharged to another physician's service on 8/9/2010. The only other available physician was Dr.(physician's name). He denied this request. I explained that there are only two inpatient physicians (see chart note from 8/9/2010) to the patient and her son. I also explained that she would probably be going back to the nursing home the next day and there was no need for transfer, she was discharged 8/10/2010. There were three (3) family members present during the discussion later that day and given the fact they stated they understood the situation. I took it upon myself to pursue no further action. I informed (Patient #1's POA) to not take any further action. I did not inform administration of this event, per my own judgment. In the future, patients will be made aware of limited physician choices. If personal conflicts arise, the nursing staff and directors, all admitting physicians, hospital administration, the medical executive committee, the hospital board, attorneys and any other parties deemed necessary, will be informed. If a resolution can not be achieved, transfer to an outside facility will be considered but can not be guaranteed."