HospitalInspections.org

Based on hospital policy review, grievance file reviews, and staff interviews the hospital failed to review, investigate, and resolve each patient's grievance within a reasonable time frame for 2 of 3 grievance files reviewed (#6 & #9).

The findings include:

Review of current hospital policy entitled PATIENT GRIEVANCE MANAGEMENT POLICY, reviewed / revised: 07/11, states under PROCEDURE 6. "Within seven calendar days, the patient will be sent a follow-up letter by appropriate facility administrator which addresses a resolution or notifies the patient that further investigation is required. The patient will be informed of an expected follow-up time to address the resolution and will be kept informed of the progress on a weekly basis. All grievances will be resolved as soon as possible with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 days."

1. Review on 09/20/2011 of a grievance file containing a "Customer Care Form" for Patient #6 revealed a grievance was received by the hospital on 05/05/2011. Details of the complaint states "Ms. (patient #6), was seen at (the hospital) ED for abdominal pain. (Patient #6) said she told the nurse she was dizzy and wanted something for pain. The nurse told her she would have to give a urine sample first before she could give her anything. (Patient #6) had to walk to the restroom by herself and she fell and hit her head in the restroom. (Patient #6) is currently admitted to (the hospital) because she had to have emergency surgery. She would like to speak with someone regarding her fall in the emergency room. Mr. (patient #6 brother) said her care on the 4th floor is fine."... Further review revealed "5/12/2011****Mr. (patient #6 brother) called back stating no one has contacted him or his sister regarding original complaint about ER. SR/RHH (Reassigned to CHS Customer Care Line).... 5/12 - Complaint originally assigned to employee #7, so reassigned to her again (not sure if she may have any investigation details). Referred to: employee #8, 5/13/2011 at 9:47:08 AM". No further documentation regarding an investigation was provided except for a letter sent to the complainant on July 19, 2011, 75 days after the original complaint, signed by employee #9, indicating the hospital staff could not reach the patient with the given telephone numbers. The letter also indicated the patient could call numbers provide if she wished for the investigation to continue.

Review of facility complaint "Timeline" documentation revealed a complaint was received on 5/5/2011 at 1109 regarding patient #6's fall in the emergency department (ED). Review revealed the complaint was assigned to employee #7 at 1129 who referred the complaint to employee #8 at 1310. Review revealed on 5/12/2011 (not timed), the patient called back to the Customer Care Line (hospital complaint line) and on 5/13/2011 at 0947 the complaint was referred to employee #8. Further review revealed a note, not dated or timed, that stated "Action Items: Attempted to call patient. Number listed no longer in service. Follow-up letter sent."

Closed medical record review shows patient #6 entered the Emergency Department on 5/3/2011 at 0447 for abdominal pain, and was seen by the physician at 0454. After CT scan it was determined patient #6 needed surgery for adhesions. The patient had surgery on 5/3/2011, and was discharged on 5/5/2011 at 1706 to home.

Interview on 9/21/2011 at 1115 with employee #8, who was the ED manager at the time of incident indicated he had reassigned the incident to employee #9. Phone interview with employee #9 on 9/21/2011 at 1000 revealed he had been assigned to investigate this incident, and was never able to contact patient #6 for further information regarding the incident. Employee #9 also indicated he was unable to recall all the particulars around the incident/investigation, and that he had no documentation to show what he had done or when, other than he had sent the letter dated July 19, 2011, 75 days after the original complaint, indicating he could not reach her.

The "Customer Care Form" with the allegations gave a phone number of patient #6's brother. This surveyor called the number provided on 9/21/2011 at 1300 and was informed that patient #6 had moved. The brother gave this surveyor patient #6's new phone number. This surveyor called patient #6 on 9/21/2011 at 1320 and was told by patient #6 that she had never received any letter regarding the investigation and also indicated she moved some time near the end of July, 2011.

Interview with the Vice president/Chief Nurse on 9/21/2011 at 1500 confirmed the investigation of this incident had not followed the hospital policy and had not been conducted appropriately.



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2. Review on 09/21/2011 of grievance #22318 for Patient #9 revealed a grievance was received by hospital staff on 03/20/2011 at 1802 during a discharge follow-up telephone call from the patient's representative (daughter), concerning quality of care issues at the hospital during an emergency department (ED) visit on 03/19/2011.

Review of "Discharge Call Manager Patient Survey" documentation revealed "...Complaint (complainant) brought mother in upon suggestion from doctor mother has parkinson dieases [sic]. The ER (emergency room) doctor and nurses treated pt (patient) as if there was nothing they could do pt felt as if she was being treated as if she was just gonna die. No one ever offered her any food or attention. Pt was very dissapointed [sic] she felt as if because she was black or older. ..." Review revealed "If a complaint/concern is voiced during the completion of the discharge phone call, ask the following: ...Do you want a Manager to call you for follow-up? YES (indicated) If YES, forward to your manager. ..." Further review revealed no available documentation of the date and time the grievance was forwarded to the ED manager for investigation. Review of a "Timeline" revealed on 05/09/2011 (49 days later) the ED manager "spoke with patient's daughter." Further review revealed "Action items: Follow up letter sent." Review of the written letter of resolution (response) revealed the letter was dated 05/09/2011 (49 days later).

Interview on 09/21/2011 at 1400 with the ED Manager (former) revealed he was the ED manager for the ED when the grievance for Patient #9 was received by hospital staff. Interview revealed he was unsure of when and how he was notified of the grievance. Interview revealed he investigated the grievance and responded to the complainant with a written letter of resolution on 05/09/2011 (49 days later). Interview confirmed the written letter of resolution was not provided to the patient within the time frame (7 days) specified by the hospital's grievance management policy. Interview revealed "I dropped the ball."

Interview on 09/21/2011 at 1534 with the Chief Nursing Officer revealed the grievance was voiced during a ED follow-up telephone call on 03/20/2011. Interview revealed the grievance was documented in the discharge call manager patient survey. Interview revealed the grievance should have been investigated and a written letter of resolution should have been mailed within 7 days after receipt. Interview revealed the staff "failed to follow through" and did not follow hospital policy.