HospitalInspections.org

Based on record review and interview the facility failed to ensure a patient's right to safe care when the facility did not ensure a patient's complaint regarding quality of care was reviewed, investigated or followed up on. (Patient #1)

Findings Include:

Review of the facility provided policy Patient Grievance (revised 2/2/17) reflected, "...a complaint expressed via a post discharge verbal communication regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay are considered to be a complaint.... A verbal complaint not resolved at the time the complaint is made by staff present, and involving one of the following concerns are considered a grievance: 5.2.1.1 The patient's care and /or service.... 5.2.5 If there is a doubt as to whether an expressed complain or concern rises to the level of a grievance, it should be referred to the Patient Relations Committee for evaluation.... 7.2 Complaints or grievances involving the members of the medical staff are forwarded to the Chief Medical Officer for review, investigation and follow-up.

Review of the facility provided policy Patient Rights and Responsibilities (revised 6/5/16) reflected, "... 4.1.12 Resolution of complaints.... 4.2.13 Prompt resolution of grievances...."

Review of the facility provided CipherHealth Care Note dated 4/18/18 at 3:42 p.m. reflected "Patient stated the PA asked him why he even came into the ER for a [sic] insect bite and them told him just take Benadryl. Patient stated he has been to Dr. three times already. The site has grown to a quarter size blister and had been drained twice. Patient is in a lot of pain to point can't sleep. Patient did not even know what to say about the PA's treatment. Patient stated he won't come back to our ER and will use the other ER in town."

During an interview on the morning of 6/26/18, Staff #9, Administrative Assistant when asked if she had spoken to patient #1 and if she had passed on the complaint about the PA, confirmed she had talked to the Patient #1 and stated, "I asked the patient if he wanted to talk to Patient Relations, he said no.... I don't pass on all the comments, if I did, it would be a lot.... I was never told to pass them on. I only pass on the ones that say they want to talk to a Patient Relations."

During an interview on the afternoon of 6/26/18, Staff #6, Sr. Director of Quality confirmed a non-clinical staff person was reviewing the concerns and stated, "It's a missed opportunity to improve the quality of care.... Staff #9 was only doing what she was told."

Based on record review and interview the facility failed to ensure the facility's Quality Improvement Performance Improvement Program was reviewing and investigating all unresolved quality of care concerns.

Findings include:

Review of the facility provided policy Quality Assurance and Improvement Plan and Program (revised 11/27/17) reflected, "
Purpose: 1.1 To develop, implement, and maintain Scope of Data Collection at a minimum, the organization will collect data in the following areas: 4.1.12 Patient perception of the safety and quality of care, treatment, and services. improvement program.

Review of the facility provided CipherHealth Care Note dated 4/18/18 at 3:42 p.m. reflected "Patient stated the PA asked him why he even came into the ER for a [sic] insect bite and them told him just take Benadryl. Patient stated he has been to Dr. three times already. The site has grown to a quarter size blister and had been drained twice. Patient is in a lot of pain to point can't sleep. Patient did not even know what to say about the PA's treatment. Patient stated he won't come back to our ER and will use the other ER in town."

During an interview on the morning of 6/26/18, Staff #9, Administrative Assistant confirmed she had talked to the Patient #1 and stated, "I asked the patient if he wanted to talk to Patient Relations, he said no.... I don't pass on all the comments, if I did, it would be a lot.... I was never told to pass it on."

During an interview on the morning of 6/26/18, Staff #6, Sr. Director of Quality stated, "The medical director sits on the Patient grievance committee.... The committee has access to clinical complaints. ... Emergency Services has their own committee. Staff #9 is not a clinical person, Staff #10 reviews all the complaints .... He's an RN ...."

During an interview on the afternoon of 6/26/18, Staff #10, RN Director of Patient Experience, stated, "I task and trend everything... I review all patient relations concerns on VERG.... I confirm if it's been escalated appropriately. I'll decide if it has been handled appropriately.... VOICE is an automated system that calls patients, based on the answers, someone in the facility will call them back.... I only look at what is in Verge." Staff #10 confirmed Patient #1's complaint was not resolved and that he had not reviewed Patient #1's complaint or any complaint that had not been escalated.

During an interview on the afternoon of 6/26/18, Staff #8, Director of Emergency Service confirmed she was not aware of patient #1's complaint.

During an interview on the afternoon of 6/26/18, Staff #6, Sr. Director of Quality confirmed a non-clinical staff person was reviewing the concerns and stated, "It's a missed opportunity to improve the quality...."