HospitalInspections.org

Based on hospital policy and procedures, medical record review, and staff interviews, the hospital staff failed to allow an adolescent behavioral health patient to speak to a patient advocate per request in 1 of 1 adolescent medical records reviewed. (Patient #5)

The findings include:

Review on 05/11/2023 of the hospital policy titled "Resolution of Patient Complaints and Grievances" with a review date of 05/02/2022 revealed "... a system-wide coordinated process for the collection, deocumentation, and resolution of patient complaints and grievances. A grievance may be filed through the hospital, or the patient may wish to escalate the grievance through the CMS (Centers for Medicare and Medicaid Services) Quality Improvement Organization, at any time ... COLLECTION OF COMPLAINTS AND GRIEVANCES: The patient or representative may present complaints or grievances via different forms of communication. Complaints or grievances received via incoming calls, written letters/email, in person or in conversation are vital to our data collection and resolution of the concerns. All hospital complaints or grievances not immediately resolved at the bedside and all patient complaints relating to physician offices, will be reported to the Director of Patient Experience to be documented and addressed ... DEFINITION(S): A "patient complaint" is a verbal complaint that is filed by a patient/representative, which can quickly be resolved by the associate(s) present at the time the complaint is expressed. A"patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Particpation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitation provided by 42 CFR § 489. ..."

Review on 05/10/2023 of the medical record for Patient #5 revealed a 17-year-old female whio presented to Hospital A's DED (dedicated emergency department) via EMS (emergency medical service) on 11/09/2022 at 2000 with a complaint "she threatened to kill herself with a butterknife and ran out into traffic." Review of the Provider note dated 11/09/2022 at 2016 revealed "Patient is a 17-year-old female who presents by EMS from local facility (Facility B) for concerns of some outburst/SI (suicidal ideations - thoughts of taking one's own life). Apparently patient has multiple psychiatric diagnoses as well as physical ... Apparently has some eating disorders ... Patient was then sent to (Facility B) locally ... Today someone was hitting the head on the wall. This then triggered the patient to some trauma previously. She has been sexually and physically assaulted at different facilities. Has seen a lot of trauma. Apparently stick better knife (sic) and started cutting on her left forearm. Per EMS she ran from the facility but patient states she just became upset and has some SI. She was brought here by EMS ... Patient initially did not talk but during my evaluation she did speak a lot ... She states that she was triggered. She does state that she wants to self-harm. She does want to vomit and purge so that she can be skinny. She states when she has the most and healthy she feels the best about herself. Denies any hallucinations. No HI (homicidal ideations - thoughts of killing someone else) ... Patient is voluntary at this time. If she does try to leave we will involuntarily commit her. When I discussed this with her she wanted to be cooperative ... Pt (patient) medically cleared. Behavior health clinician has assessed the patient will try to find outpatient resources for placement (dual diagnosis with purging/eating disorder too.)." Review of the Provider note signed 11/10/2022 at 1116 revealed "Patient continuing to require observation and monitoring for Psychiatric care ... Pt w/SI (with/suicidal ideation), behavioral issues. Psych (psychiatry) looking for placement. Accepted to (Hospital C), IVCed (involuntary committed) per their request ..." Review of the Provider note signed 11/12/2022 at 0653 revealed "Notes: I was called to the bathroom or (sic) the patient was aggressively combatting for our staff. Saw her trying to spit on staff as well as bite them. I ordered Haldol (antipsychotic medication), Ativan (sedative medication), and Versed (sedative medication) to sedate her. Please for (sic) called as well. Patient was eventually put back in her room and became cooperative. Patient is scheduled to be transferred to an inpatient unit today." Review of the Nurse note dated 11/12/2023 at 0746 revealed "Pt requests to speak to patient advocate. spoke with Charge RN (Registered Nurse), and house sup (supervisor). Explained that all are aware of her concerns and will speak to her as available. VM (voice message) left for BH (behavioral health) intake to come speak to patient. Await BH response." Review of the medical record revealed Patient #5 was transferred to Hospital C on 11/13/2022 at 0832.

Telephone interview on 05/10/2023 at 1645 with RN #1 revealed she remembered Patient #5 had been in the ED several days and had assaulted staff on night shift. Interview revealed the local police had to be called and involved. Interview revealed the Patient Advocate's business card was at the charge nurse's desk. Interview revealed RN #1 did not recall if she called the Patient Advocate or if Patient #5 spoke with the Patient Advocate.

Interview on 05/12/2023 at 0842 with PE #2 revealed she had searched through all of her notes and did not have anything where Patient Experience was asked to speak to Patient #5. Interview revealed PE #2 verified no one on her team had received any information about Patient #5 requesting to speak with them. Interview revealed patients typically notified the nurse they want to speak with a Patient Experience and the nurse notifies Patient Experience via an email. Interview revealed sometimes they are notified via a telephone call.

Follow up telephone interview on 05/12/2023 at 1230 with RN #1 revealed she "talked" with Patient #5 "a little bit." Interview revealed Patient #5 was out of it and as far as RN #1 knew Patient #5 wanted to talk to the Patient Experience because she "didn't like to be held down." Interview revealed RN #1 "didn't call the Patient Experience."
NC00195389