HospitalInspections.org

Based on record review and interview, facility staff failed to ensure that they provided patients/patient representatives filing grievances with a timely response in 4 of 7 patient grievances (Patients #22, #23, #24, #25), out of a total universe of 7 grievance files reviewed.

Findings include:

A review of the facility's policy #6794238 titled, "Patient Complaints and Grievances, AW (Ascension Wisconsin)," last reviewed 08/12/2019 revealed, " ...The department leader or designee will inform the patient of the specific time frame for review and response during initial contact with the patient. Most grievances should be reviewed and resolved with a final grievance response letter mailed to the patient or patient's representative within 7 days. If the grievance is not resolved, or if the investigation is not or will not be completed within 7 days, the patient shall be informed of the progress of the investigation, and given a reasonable timeframe for completion ...The department leader or designee responsible for reviewing the grievance should be updating the ERS (Event Reporting System) feedback ticket with follow up notes, action plans, and contact dates of phone calls or contacts made with the patient ..."

On 06/17/2021 at 9:00 AM, a review of Patient #22's grievance file #MMD2582627 revealed the grievance was filed via telephone on 03/08/2021. There was no documented evidence found that #22 was informed of the progress of the investigation or given a timeframe for completion. The response letter was mailed on 03/22/2021, 14 days after the grievance was filed.

On 06/17/2021 at 9:10 AM, a review of Patient #23's grievance file #BYQ2594085 revealed the grievance was filed via telephone on 04/15/2021. There was no documented evidence found that #23 was informed of the progress of the investigation or given a timeframe for completion. The response letter was mailed on 04/28/2021, 13 days after the grievance was filed.

On 06/17/2021 at 9:20 AM, a review of Patient #24's grievance file #DGK2605976 revealed the grievance was filed via telephone on 05/26/2021. There was no documented evidence found that #24 was informed of the progress of the investigation or given a timeframe for completion. The response letter was mailed on 06/08/2021, 13 days after the grievance was filed.

On 06/17/2021 at 9:25 AM, a review of Patient #25's grievance file #WEE2586535 revealed the grievance was filed via letter on 03/22/2021. There was no documented evidence found that #25 was informed of the progress of the investigation or given a timeframe for completion. The response letter was mailed on 04/05/2021, 14 days after the grievance was filed.

During an interview on 06/17/2021 at 10:09 AM with Patient Relations N, when asked about the expectations for responding to patient grievances, N stated, "The majority of responses are resolved within 7 days." When asked if patients are notified if the investigation may take longer than 7 days, as defined in the facility policy, N stated, "There should be notes within the ERS to show," that contact was made with the complainant. When asked to confirm that there was no documented contact prior to the final response letter found in grievance files of Patient #s 22, 23, 24, and 25, N stated s/he would, "Expect there to be a note. I'll take a look again." There was no further information received from N.

Based on record review and interview, the facility staff failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 1 of 11 required areas (Medical Screening Exam).

Findings include:

The facility staff failed to define which individuals have been determined to be qualified to perform a medical screening exam. See tag 2406.

Based on record review and interview the facility failed to define which individuals have been determined to be qualified to perform a medical screening exam in 1 of 1 facility bylaws of the medical staff reviewed.

Findings include:

A review of the facility's document titled, "Ascension NE Wisconsin Medical Staff Bylaws," amended May 2018, revealed no evidence of a statement defining who was qualified to perform a medical screening exam.

A review of the facility's policy #8304980 titled, "Emergency Medical and Treatment (EMTALA), AW (Ascension Wisconsin)," last reviewed 07/28/2020 revealed, " ...'Qualified Medical Person or Personnel (QMP)' means an individual in addition to a licensed physician who is licensed or certified and who has demonstrated current competence in the performance of Medical Screening Examinations ...A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., Qualified Medical Person ...Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval ..."

During an interview with Quality Coordinator I on 06/17/2021 at 2:15 PM, I stated that s/he was not able to find any documentation within the Medical Staff Bylaws or within a facility-specific policy to indicate that the facility's governing body or medical staff defined and approved who is qualified to perform a medical screening examination.