HospitalInspections.org

Based on record review, policy titled Grievance and Patient Problem Solving Process (policy # RI1.122, revised 4/2011) and interviews, the hospital failed to follow the established grievance process by not investigating a verbal grievance expressed by 1 of 1 sampled patients in a total of 9 (patient #1). Findings:

Review of the closed ED (Emergency Department) medical record for patient #1 revealed she presented to the ED on 7/21/2011 with complaints of chest pain and shortness of breath. Review of the ED Daily Log revealed patient #1 registered at 1:42 PM and was triaged by S11 ED/RN at 1:44 PM. The record indicated patient #1 was assessed as 3/9 (urgent priority) with vital signs of: blood pressure-111/68; pulse rate-75; respirations-16; pulse oximetry- 97% on room air and temperature-97.8. Patient #1 had a history of cardiac disorder with heart blockages that required 5 stents. Further review of the ED record revealed patient #1 took 4 nitroglycerin (vasodilator) tablets prior to arrival without relief plus SOB (shortness of breath) and was burping in triage. Patient #1's pain assessment documented at 1:44 PM revealed the intensity was 8 out of 10 (0 being no pain and 10 being extreme). Further review revealed S6 MD Cardiologist was listed as patient #1's physician. An EKG (electrocardiogram) was obtained at 2:30 PM which indicated normal sinus rhythm.

Further review revealed patient #1 was placed in an ED examination room at 3:32 PM. Review of the Emergency Physician Record revealed patient #1 was evaluated by S8 ED physician at 3:35 PM with a pain level of 8 out of 10. S8 also ordered a "Stat Cardiology Admit", Metoprolol Tartrate 25 mg, Dilaudid 1 mg injection, Nitroglycerin 2% ointment 0.5 application at 3:38 PM PM and review of the ED MAR (medication administration record) revealed the medications were administered at 4:28 PM.

Review of the 2011 ED Call Panel revealed the Christus Schumpert Health System Cardiology group was on-call on 7/21/11. Review of the ED record revealed on 7/21/11 at 4:48 PM S6, patient #1's cardiologist was paged and patient #1 went to the Heart Catheterization Lab at 5:15 PM for a left heart catheterization and stent placement.

On 10/31/2011 at 12:45 PM an interview was held with S3 RN Patient Advocate who stated all grievances go to the grievance committee which meets monthly and was chaired by Dr. S7 Medical Director of Quality. S3 reported the grievances were investigated by the department managers where the grievance originated and then the manager and the investigative findings go to the grievance committee for review. S3 added if the grievance involved care and service, the patient always received feedback (letter) after completion of the investigation. She said she sends a letter by regular mail to the patient acknowledging the grievance and a registered letter after completing the investigation.

S3 RN further stated when a patient makes a complaint and the issue cannot be resolved at the bedside, it becomes a grievance. S3 did say many times the unit manager takes care of patient complaints but she was unsure if the manager documents all complaints. Continued interview revealed when a patient has a complaint about a physician, the complaint goes directly to Dr. S7 and she takes care of the issue. S3 further stated the grievance committee does not see documentation of that peer review.

In an interview on 0/31/11 at 1:20 PM, interview with S1 RN ED Manager explained she received a call from S6, patient #1's cardiologist who said "we were trying to give his patients away". S1 stated that was not what was happening but would find out what did happen. S1 stated she talked to S4 RN Director of Cath Lab and PCU and to S8 ED physician. S1 stated it was her understanding that S8 kept trying to get patient #1 to see S9, the cardiologist on call but that the patient insisted on seeing her own cardiologist. S1 stated it seemed to her that S8 ED physician did not read her chart to know who her cardiologist was. S1 also stated the ED was very busy that day during that time and not calling her cardiologist was an oversight, or they just did not listen to the patient.

In a telephone interview on 11/01/2011 at 3:15 PM ED Dr. S8 stated she did not recall an ED patient who asked to see her own cardiologist. S8 stated she started in the hospital's ED on 6/2011 and may not have been aware of the ED procedures regarding which group of cardiologists was on call at certain times. S8 said she relies on the ED nurses to direct her regarding on-call physicians. S8 said if a patient requests that she contact their own cardiologist, she would do it because it makes it easier for her to know who to call. S8 added that if she failed to contact a physician requested by the patient, it was either a mistake on her part or the patient did not ask that she call a particular physician.

In a second interview on 11/01/11 at 3:45 PM, S3 Patient Advocate confirmed she was not at the hospital the day the issue with patient #1 was brought to the attention of S6 Cardiologist and Administration. S3 stated she claimed the responsibility for not investigating the complaint because she was told the patient knew her, had her phone number and intended to call her. S3 further stated she left it at that, even though patient #1 never called. S3 stated she probably should have called the patient herself. S3 confirmed the hospital did not act on this incident and the general consensus was that the problem was a physician issue rather than a delay in treatment/quality of care. S3 stated nurses do not handle physician issues which would be addressed by peer review. S3 also stated all patients have the right to see the physician of their choice, especially a specialist, even in the ED.

S3 Patient Advocate confirmed she received an e-mail from S4 RN, Nursing Director of Cath Lab and PCU to inform her of the issue with patient #1. Review of a copy of the e-mail dated 7/22/11 from S4 to S3 revealed it was sent to S1 RN ED nurse manager and the Quality manager (accepted another position at another hospital 1 week after this incident). Attached to the e-mail was the grievance expressed to S4 by patient #1. S3 stated she could not recall if she contacted S6 Cardiologist or not.

Interview on 11/02/2011 at 10:00 AM with S12 RN revealed she worked 7/22/11 on PCU (progressive care unit) where sampled patient #1 was admitted after the heart catheterization and stent placement on 7/21/2011. S12 stated she was assigned the care of patient #1 and during the discharge process, patient #1 told her about the events in the ED about waiting for treatment and the confusion about the physician. S12 stated patient #1 asked to see the supervisor so she called S4 RN, Cath Lab Director who came to see patient #1 after S6 Cardiologist had rounded at 8:30 AM. S12 RN stated she did not stay in the room during the conversation with S4 RN and patient #1.

On 11/02/2011 at 10:45 AM S1 RN ED Nurse Manager stated that when a grievance pertained to her department, she was responsible for the investigation and would call the complainant to make sure she had the same information that was reported. S1 RN verified there was no documentation the verbal grievance expressed by patient #1 to administration was investigated by her. S1 confirmed that she failed to follow the hospital's established grievance process.

Review of "Grievance and Patient/Family Solving Process Policy # Rl1.122, reviewed 2/08 and revised 4/11, described a grievance as, 'A written or verbal complaint by a patient or the patient ' s representative regarding the patient ' s care ' when the complaint has not been resolved by staff present to the patient ' s satisfaction ' , abuse or neglect, or the hospital ' s compliance with the Conditions of Participation".

Based on record review and interview, the hospital failed to honor a patient's request by not promptly notifying the designated cardiologist identified in the medical record for 1 of 8 Emergency Department (ED) patients (patient #1) in a total sample of 9. Findings:

Review of the closed ED medical record for patient #1 revealed she presented to the Emergency Department on 7/21/11 with complaints of chest pain and shortness of breath. Review of the ED Daily Log revealed patient #1 registered at 1:42 PM and was triaged by the RN at 1:44 PM. Patient #1 was assessed as 3/9 (urgent priority) with vital signs of: blood pressure-111/68; pulse rate-75; respirations-16; pulse oximetry- 97% on room air and temperature-97.8. Patient #1 had a history of cardiac disorder with heart blockages that required 5 stents. Further review of the ED record revealed patient #1 took 4 nitroglycerin (vasodilator) tablets prior to arrival without relief. The record indicated the patient complained of SOB (shortness of breath) and was burping in triage. Patient #1's pain assessment, documented at 1:44 PM, revealed the intensity was 8 out of 10 (0 being no pain and 10 being extreme). Further review revealed S6 MD Cardiologist was listed as patient #1's physician. An EKG (electrocardiogram) was obtained at 2:30 PM which indicated normal sinus rhythm.

Further review revealed patient #1 was placed in an ED examination room at 3:32 PM. Review of the Emergency Physician Record revealed patient #1 was evaluated by S8 ED physician at 3:35 PM with a pain level of 8 out of 10. S8 also ordered a "Stat Cardiology Admit ", Metoprolol Tartrate (beta blocker) 25 mg, Dilaudid (narcotic pain reliever)1 mg injection, Nitroglycerin 2% ointment 0.5 application at 3:38 PM PM and review of the ED MAR (medication administration record) revealed the medications were administered at 4:28 PM.

Review of the 2011 ED Call Panel revealed the Christ Schumpert Health System Cardiology group was on call on 7/21/11. Review of the ED record revealed on 7/21/11 at 4:48 PM the cardiologist on call for the Schumpert Cardiology group was paged. At the same time, S6, patient #1's cardiologist (from Cardiology Associates) was paged and patient #1 was taken to the Heart Catheterization Lab at 5:15 PM for left heart catheterization and stent placement performed by S6.

In an interview on 10/31/11 at 1:20 PM, S1 RN ED Manager explained she received a call from S6, patient #1's cardiologist who said "we were trying to give his patients away" . S1 stated that was not what was happening but would find out what did happen. S1 stated she talked to S4 RN Director of Cath Lab and PCU and to S8 ED physician. S1 stated it was her understanding that S8 kept trying to get patient #1 to see S9, the cardiologist on call but that the patient insisted on seeing her own cardiologist. S1 stated it seemed to her that S8 ED physician did not read her chart to know who her cardiologist was. S1 also stated the ED was very busy that day during that time and not calling her cardiologist was an oversight, or they just did not listen to the patient.

On 11/01/2011 at 10:05 AM an interview was held with Dr. S6 cardiologist who stated he "vividly" recalled when patient #1 was in the ED on 7/21/2011, he was on the second floor of the hospital seeing another patient. S6 said patient #1 told him that she had a long wait in the ED but understood they had an emergency that delayed everything. S6 continued to say that patient #1 told him after the ED nurse completed the EKG (electrocardiogram); she told the patient that she would contact Dr. S9 who was on call for the hospital's cardiology group. S6 said at that time the patient told the nurse that she knew Dr. S9, did not have anything against the doctor, but he (Dr. S6) was her doctor and she wanted them to call him. Dr. S6 said patient #1 told him that ED Dr. S8 was adamant that she see the hospital's cardiology group. S6 said patient #1 told him that after she told ED Dr. S8 that she wanted to see him, the ED doctor came back into her room to ask if she knew his telephone number

On 11/01/11 at 10:52 AM, during an interview with S9 cardiologist, a member of the Schumpert cardiology group, revealed the ED physician performed the medical screening examination to determine the acuity; then called the needed specialist from the group on call which meant the patient would not always see their own physician. But, he said, if a patient requested their own physician, that was who they saw unless their doctor does not work here. At that point, the patient can choose to transfer to the hospital where their physician practices or see who was on call. The event of patient #1's ED visit on 7/21/11 was discussed with S9 and he stated he never saw sampled patient #1 when she was in the ED. S9 stated S8 ED physician was new to the hospital as of July 2011 and must have missed the fact that S6 Cardiologist was documented on patient # 1's chart as her cardiologist.

In an interview on 11/01/11 at 3:45 PM, S3 Patient Advocate confirmed she was not at the hospital the day the issue was brought to the attention of S6 Cardiologist and Administration. S3 also stated all patients have the right to see the physician of their choice, especially a specialist, even in the ED.

.

Based on record review, policy titled "Informed Consent" (revised 2/09) and interviews, the hospital failed to ensure a properly informed consent was obtained for 3 of 4 sampled patients who had invasive procedures (patient #1, #2 and #4). Findings:

Patient #1. Review of the closed record revealed this was a 71 year-old who presented to the Emergency Department on 7/21/11 at 1:42 PM with complaints of chest pain and shortness of breath unrelieved by 4 Nitroglycerin (vasodilator) sublingual tablets prior to arrival at the ED. Further review revealed that patient #1 rated her chest pain at 8/10 (0-none and 10-acute) during triage by S11 ED/RN at 1:44 PM. According to documentation, patient #1 went to Cath Lab at 5:15 PM for a left heart catheterization procedure and stent placement.

Review of patient #1's consent for the procedure titled "Medical Treatment or Surgical Procedure Information" dated 7/21/2011 at 1730 (5:30 PM) revealed it did not contain the patient's name or the physician's name in the specified areas on the consent form for a PCTA (Percutaneous Coronary Angioplasty) Stent Placement with IV Conscious Sedation. Further review revealed the cardiologist signed the consent after the procedure on 7/21/2011 at 1852 (6:52 PM).

Patient #4. Review of the closed medical revealed this was a 66 year-old who presented to the ED on 7/21/2011 at 7:13 PM with chest pain. Further review revealed the EKG indicated the patient had a myocardial infarction and he went to Cath Lab for a left heart cath procedure.

Review of the consent form titled "Medical Treatment or Surgical Procedure Information" dated 7/21/2011 at 11:55 PM revealed it did not contain the patient's name or the physician's name in the specified areas on the consent form for a Left Heart Heart Catherization with IV Conscious Sedation.

Patient #2. Review of the closed medical record revealed this was a 77 year-old admitted on 7/21/2011 for a heart catheterization procedure. Review of the consent form titled "Medical Treatment or Surgical Procedure Information" dated 7/21/2011 revealed the patient signed the consent for a Left Heart Heart Catherization with IV Conscious Sedation at 11:00 AM, but the form did not contain the patient's name or the physician's name on the specified sections of the consent. Further review revealed the physician signed the consent at 3:00 PM, just prior to the procedure.

Review of the hospital's Informed Consent Policy revealed, "The physician is responsible for obtaining informed consent from any patient or responsible person for all surgery procedures or specific diagnostic test procedures". The policy indicated the consent form should be complete and contain the complete name of the physician who would perform the surgery or diagnostic test/procedure, as well as the patient's full name. In an interview on 11/02/2011 at 2:15 PM, S1 RN confirmed the consents were incomplete for patients #1, #2, and #4.