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Based on interview, a review of the hospital grievance policy, and 7 of 10 applicable grievance files, it is revealed that, although the hospital informs patients when an investigation surpasses the average 7 day response time, the hospital 1) has an average 26 day resolution response time for 5 of 7 applicable grievance files reviewed , and 2) two grievances #8 and #5 begun on 12/16/13 and 1/2/14 respectively, had no resolution letters at the time of survey of 1/15 and 1/16/14.
Hospital policy for " Patient Complaint and Grievance Procedure " states in part, " 1. All grievances will be addressed as quickly as possible and if the investigation cannot be completed within seven (7) calendar days from receipt, a written notice of acknowledgement including an estimated time for the final response will be provided to the patient/representative. "
Review of 10 grievance files reveals 2 non-patient grievances, 1 billing grievance, and 7 grievances related to patient care. Interview with the Director of Risk Management reveals that conducting thorough investigations often can take more than 7 calendar days, and that the hospital does send letters informing the complainant that the investigation is ongoing.
Review of the 7 applicable grievance files reveals that the hospital did send letters to complainants for investigations going beyond 7 days. However, the hospital resolution of investigations is found to be well outside the average of 7 days (22 days) for 5 applicable grievances related to patient care, and 2 of the 5 applicable grievances had no resolution after 25 days and 11 days respectively on the day of survey.

Based on a review of 10 patient records, it is revealed that for patient #1, the hospital failed for a time to follow his expressed instructions related to emergency contacts.

Patient #1 was a male in his early 90's admitted to a hospital in late November 2013 with increased shortness of breath and +2 edema to his legs and feet. Also noted were complaints of nausea and vomiting, abdominal distension, and difficulty swallowing. Patient #1's wife and son were designated as emergency contacts in that order, and his daughter was added later as the third in line to receive contact from the hosptial. Patient #1 is noted as having capacity to make his own decisions.
On 12/5 following a family meeting, the daughter asked to be the point person, or the first person listed on the emergency contact form. It was explained to her that patient #1's wife, his son, and lastly he daughter were noted by patient #1 to be informed of emergencies in that order. Following her request, staff checked with patient #1 who wanted the contacts to remain the same.
It was noted by the hospital some days later, that the emergency contact form had been changed to reflect the daughter as the first contact, against patient #1's expressed wishes. While hospital representatives do not know how this occurred, they believe that the daughter called the hospital at some point and was able to convince staff to make the change. When discovered, the form was changed back to reflect the patient's wishes. However, hospital staff changed the form against the expressed desires of patient #1, and therefore, failed to include patient #1 in the development and implementation of his plan of care.

Based on a review of 10 patient records, it is revealed that the guardian for adolescent patient #6 who presented to the emergency department, 1) received no interpreter services when signing the emergency department consent to treat, nor until almost three hours later after the guardian's refusal to allow inpatient treatment, and 2) the hospital failed to consult patient #6's guardian regarding his history; instead using his older sister who is not documented to be an adult.

Patient #6 is a young adolescent male who presented to the ED in early January at 0930 due to hallucinations, bizarre behaviors and suicidal ideations for 3 days. Patient #6 was accompanied by his sister and his mother. Patient #6 and his sister are fluent in English, however patient #6's mother is non-English speaking. No age is given for the older sister.
Consent for treatment is found in the record for 0931 am. The consent is printed in English, and no documentation reveals that interpreter services were obtained for the mother prior to her signature as found on the consent. Nursing documentation reveals "hx primarily obtained from patients older sister. Mother is non-English speaking."
Following evaluation, it was decided that patient #6 required in-patient care. A psychiatric evaluation note of 1215 states "Spoke with Dr. __ and Dr. __, both feel pt will need inpt hospitalization. Mother denies wanting to place pt. will bring in language line interpreter to help convince mom of the importance of treatment."
Based on documentation, the hospital failed to obtain interpreter services for the non-English speaking mother of patient #6 for consent to treat. Further, the hospital utilized the patient's sibling who is not documented as an adult, rather than the mother to obtain a history. Not until approximately three hours following patient #6's presentation when it was determined that patient #6 would require inpatient services, did the hospital obtain interpreter services to inform the mother.

Based on an onsite investigation including review of the emergency department record of patient #7 who was restrained in 4-point restraint for approximately ? hour, it is revealed that no physician order is found.


Patient #7 is an adult male in his mid-thirties who presented to the emergency department (ED) in early January at 1912 via ambulance with a chief complaint of seizure activity. Patient #7 revealed a history of benzodiazepine, cocaine, marijuana and alcohol use, as well as a having 5 recent seizures. On arrival, he was found to be intoxicated, combative, and expressed thoughts of harm to self and other. Patient #7 asked staff to put him in restraints because he wanted to kill himself. Patient #7 was placed in 4-point restraints at approximately 1927 due to combativeness.
Review of the record reveals no physician order for restraint. The hospital failed to restrain patient #7 in accordance with the order of a physician.

Based on a review of 10 patient records, it is revealed that patient #8 of 6 closed records, had no discharge summary.

Patient #8 was a male in his early 70's who expired on 12/1/2013. Review of the record on 1/15/14 during survey revealed no discharge summary. The hospital failed to maintain a complete record for patient #8.