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Based on the findings detailed throughout Tag A0115, including observation, interviews, review of medical records and review of hospital documents, including policies and procedures, it was determined that this CONDITION IS NOT MET.


As evidenced by examples identified throughout the body of this report, the cumulative effect of these systemic problems resulted in the governing body failing to ensure that patients' rights were protected and promoted.


Reference deficiencies written at Tag A0115

Reference deficiencies written at Tag A0123

Reference deficiencies written at Tag 0144

This CONDITION IS NOT MET as evidenced by:

Based on the findings detailed throughout Tag A0123 and Tag A0144, which included observation, interview, review medical records, grievance files, hospital policies and procedures and other documents, it was determined that the hospital failed to protect and promote each patient's rights.

The hospital's failure to do so resulted in patients not receiving complete information regarding grievances filed and patients not receiving care in a safe setting.

Based on interview, review of hospital policy and review of hospital grievance files, it was determined that the hospital failed to provide all patientsrepresentatives with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 5 of 5 grievance files reviewed. The hospital's failure to do so resulted in 5 patients/representatives (Patients #1, #2, #3, #4 and #5) not being provided with their rights to complete information involving the grievances that had been filed.

Findings include:
On May 24, 2016, the log for grievances received in the preceding 6 months was reviewed. All 5 grievances which were identified as containing issues pertaining to patient care issues were reviewed.

On May 24, 2016, at 2:40 PM, interviews were conducted with the Director of Risk Management (DRM) and another person from Risk Management, The policy and procedure for processing grievances was discussed, as were the findings in the individual grievance files.

Grievance #1
A written statement dated March 11, 2016 was found in the grievance file. The statement contained information about events that occurred in the Emergency Department (ED) that date, which involved care provided to Patient #1. The statement included comments from an ED bystander who had reportedly stated that the ED greeter had not made a timely response to a patient who had presented with an emergent situation, specifically not calling a code in a timely manner.

No followup was documented in the file and the unanticipated death was not referred to the Code Committee for review.

Grievance #2
On January 12, 2016, a written statement from a patient was received via a patient satisfaction survey. The patient expressed dissatisfaction with the behavior of a provider, as well as with her/his pain management.

The hospital person who was responsible for reviewing and replying to grievances stated that s/he did not think the statement was considered a grievance because it was received during a patient satisfaction survey.

Review of the file revealed that the statement was identified as a grievance, but the statement had not been processed as a grievance per the hospital's own policy and procedure.

Grievance #3
On January 15, 2016, the spouse of the patient complained in person about care provided to the patient in the ED.
Review of the grievance file revealed that the ED Medical Director had reviewed the care provided and found that the care had been appropriate.
The grievance file contained documentation from the ED Medical Director which stated that s/he had called the spouse, per the patient's request. The file contained documentation that the spouse had called again with a concern about a specific aspect of the care provided.
The final letter to the patient, dated February 2, 2016, did not contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Grievance #4
On March 20, 2016, a complaint was received from a patient spouse. The complaint was filed via the hospital's website. On April 29, 2016, a response was made to the complainant which did not answer or address the issue addressed in the complaint.
The DRM stated that the complaint had not been processed as a grievance, but acknowledged that the complaint met the criteria for a grievance.
The DRM stated that the decision on how to process the complaint had been made by the person who provided the initial screening of complaints and grievances.


Grievance #5
On April 20, 2016, a phone call was received by the hospital from the mother of a pediatric patient. The mother stated that the patient had been seen in the ED, but the ED provider had missed a diagnosis of pneumonia, which was made by a physician at another facility.
The grievance file contained documentation that the care had been reviewed by the ED Medical Director who determined that the care provided had been appropriate.
A letter dated May 11, 2016 was sent to the mother. The letter did not state that the care had been reviewed by the ED Medical Director, nor did the letter contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date of completion.

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Based on observation, interview, review of patient medical records and review of hospital documents, it was determined that the hospital failed to ensure that Patient #1 received care in a safe setting in the hospital's Emergency Department (ED). The hospital's failure to do so potentially placed all patients of the ED at risk for receiving care in an unsafe setting.


Findings include:

PATIENT #1 - HOSPITAL REVIEW AND INVESTIGATION INTO CARE

A complaint was received by the Department of Health which stated that on March 11, 2016, a patient had been brought to the ED in a private vehicle, and had been "in full cardiac arrest". The complaint stated that the "front desk assistant had no training or reference material informing [her/him] of what to do in said situation and there was a significant delay in care as a result...[the patient] later died, it is unknown to me if the delay in care was a factor..."

During the onsite investigation visit of May 19, 2016, the medical record for the ED visit of March 11, 2016 was reviewed and the Director of Quality Assurance (DQA) and the Clinical Quality Assurance Specialist (CQAS) were interviewed.

Review of the medical record revealed that the medical record was incomplete. No documentation was found in the medical record that described the initial assessment of the patient or when and how cardiopulmonary resuscitation (CPR) begun, or by whom.

Interview with the DQA and the CQAS revealed that, while the medical record had been reviewed by various individuals, as of May 19, 2016, approximately 2 months after the event, the medical record was still incomplete. The DQA stated that CPR had been started in the privately-owned vehicle that had brought the patient to the hospital. S/he stated that CPR had been started by a Registered Nurse (RN) who was an employee of the hospital, but the RN was not employed in the ED, and had been off-duty at the time. None of the initial assessment or CPR efforts were contained in the medical record. The DQA acknowledged that the incomplete medical record did not accurately reflect resuscitation efforts for the patient.

During the same interview, the DQM stated that the events should have been reviewed by the "Code Committee", but had not been. The CQAS stated that all "codes" were also reviewed by the Manager of the Critical Care Unit, but s/he did not think that had happened. The DQM stated that a Root Cause Analysis (RCA) had not been completed.

On June 2, 2016, this investigator received an email from the Chief Nursing Officer which contained a chart of various committees at the hospital. One of the committees documented in the chart was the "Code Committee". The purpose of the Code Committee was noted to be to "Review code data, monitor trends, address concerns and evaluate equipment, practice policy and process changes". The Code Committee was noted to report to the Critical Care Committee Quality and Standards".

Review of internal hospital documents revealed an email chain that contained the following documentation:
March 18, 2016: Documentation from the DRM with a "Note: Please take a look-believe it is a DOA [dead on arrival].
May 12, 2016: Documentation from the DRM to the person in Risk Management who screened cases for further review. The email stated that the DRM had called the Clinical Director of the ED and left "offer for RCA".
May 12, 2016: Documentation from the screener in Risk Management. The event "doesn't appear to be a reportable event. If [Clinical Director of the ED] wants an RCA we can help with that."
May 12, 2016: Documentation from the DRM - "need to report to insurance-questions about whether we called a timely code".
May 18, 2016: Documentation from [Manager of Patient Access, the person who supervised the ED front desk "greeters"]. The greeter at the desk during the events involving Patient #1 had reported a ""delay with the charge nurse coming out to the lobby to evaluate the patient in the vehicle".

Interviews and review of the patient's medical record revealed that, approximately 2 months after the event involving Patient #1, the medical record had not been completed; a review by the Code Committee had not been conducted; and review of the unanticipated death had not been conducted by the Manager of the Critical Care Committee or by Peer Review; and the hospital had not conducted a formal internal investigation into events around the death of the patient or why the death had not triggered reviews at multiple junctures.


EMERGENCY DEPARTMENT (ED) FRONT DESK GREETERS
Based on observation, interview and review of hospital documents, it was determined that the hospital failed to assure that the ED front desk was staffed with personnel who were at the front desk 100% of the time and who had orientation and written guidelines for how to perform their jobs. The hospital's failure to provide staff who were available at all times, with orientation and guidelines to perform their jobs, placed all patients who presented to the ED lobby at risk for unmet emergency care needs.
At 1 PM on 5/19/2016, this investigator, accompanied by the Director of Quality, observed Patient #2 in the hallway off of the lobby of the hospital's Emergency Department (ED). The patient was on her/his hands and knees, rocking to and from and holding an emesis (vomit) bag. After observing the patient and noting that the patient was not attended, this investigator approached the patient.
In the meantime, 2 hospital Registered Nurses, both of whom said they were not ED nurses, stopped to see if they could assist the patient. The greeter from the front desk then approached the patient and stated that s/he would get the patient "checked in".
At 1:10 PM, the front desk greeter was observed at the front desk assisting another person. The Director of Quality was asked to have the greeeter call the back for a clinician to attend to the patient. The Clinical Director for ED Services came out to the lobby, went back to the clinical care portion of the ED and returned with a person who was identified as the Charge Nurse for the day. The patient was assisted to a wheelchair and taken to the back.
The greeter was asked why Patient #2 had been on the floor, and had not been attended to immediately. The greeter stated that she had gone to the "back", the clinical care area because the ED had just received patients from 3 major accidents. S/he stated that she had seen the patient on the floor, and had spoken to the patient. S/he stated that the patient had complained of "abdominal pain", which her list stated was not urgent.
At 1:20 PM, Greeter #1, the greeter at that time, was then interviewed and asked to describe her/his job responsibilities. The greeter stated that when a patient comes to the lobby s/he will call the nurse, but s/he first tries to "figure out" if the need is "urgent". The greeter described "urgent" as chest pain or a heart attack. When asked to describe how s/he would know what was urgent or not, the greeter stated that s/he had a list of conditions which were considered "urgent triage cases". The greeter stated that her/his orientation had been 3 weeks of training by a co-worker.
The greeter stated that s/he usually works half of the shift alone and half of the shift with a security guard. The greeter stated that when s/he needed to be relieved for breaks or lunch, the registration people provided the relief.
The greeter was asked to describe how s/he would react if a patient was in a car, and the front desk staff were told the patient needed help immediately. The greeter stated that if the patient could not walk in s/he would call the charge nurse immediately and use the page system to call for help. The greeter was able to describe how to use the "code button" and the voice paging system to call for help.
The greeter provided a copy of the written guidelines attached to the inside wall of the front desk. The greeter stated the guidelines were used by the greeters to determine which patients needed to been seen immediately and included the term "triage alert", "call triage nurse to assess" and "have triage nurse assess immediately, if not available call charge".
Review of the position descriptions for Patient Registration Specialist I and II (known as "greeters"), revealed that the education requirement for both was "high school diploma or GED required" and experience for Specialist I was "minimum one (1) year patient registration or health care front office experience required. Patient Registration certification may be substituted for experience. Experience for Specialist II was a minimum of 2 years of the same experience.

Based on interviews and review of hospital documents, including Medical Staff bylaws and physician contracts, it was determined that the hospital failed to ensure that the emergency services organization and direction requirements were met. The hospital's failure to do so resulted in a lack of provider and staff qualifications being determined by the medical staff, lack of complete position descriptions, lack of an organizational chart and lack of a complete and accurate Scope of Services for the Emergency Department.

Findings include:

MEDICAL STAFF BYLAWS
On May 24, 2016, at 1:30 PM, the Director of Medical Staff Services was interviewed and asked to provide documentation that the medical staff had defined the qualifications of medical staff and other providers in the ED and was unable to do so. It was determined that the hospital failed to ensure that the emergency services organization and direction requirements are met.

The Director was asked to provide a copy of the job description for the ED Medical Director. The Director provided pages 4 & 5 of the contract between the contracting physician's group and the hospital, which outlined job duties. The document did not specify the name of the hospital, did not specify what board-certification the medical director must have, or if board certification was required, and did not specify the amount, or type, of experience the medical director must have. The document did not have a date the job description was effective, or for how long the job description was effective, when the document would be reviewed, or a signature.

The document did not specify the name of the hospital; did not specify criteria for qualifications for the medical director. The document did not have a date the job description was effective, when the document would be reviewed, or a signature of the physician or a hospital representative.

The Medical Director was interviewed on May 24, 2016 and stated that s/he had board certification in Family Medicine (verified by review of the physician's credentialing file). The Medical Director stated that the hospital accepted physicians who were board-certified in either Family Medicine or Emergency Medicine, and there was one ED physician who was board-certified in Internal Medicine and had been "grandfathered" in.

A second ED physician, who stated that s/he had formerly been the ED Medical Director, stated that s/he was board-certified in Family Medicine (verified by review of the physician's credentialing file).


POSITION DESCRIPTIONS
ED Medical Director - See above under "Medical Staff Bylaws"

The hospital's policy and procedure "Triage for Emergency Department" stated "An experienced RN who is trained in triage, and is ACLS certified, will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity..."

Triage Nurse/Staff Nurse - The Director of Clinical Services for the ED stated on May 19, 2016 that there was no job description specific to triage nurses. The Director stated that ED staff nurses were assigned to triage duties in the absence of a dedicated triage nurse; however, the ED staff nurse job description did not include triage duties.

Based on interview and review of hospital documents, it was determined that the hospital failed to assure that the Emergency Department (ED) services were organized under the direction of a qualified member of the medical staff. The hospital's failure to do so resulted in the Governing Body not determining which members of the medical staff were qualified to supervise in the ED.

Reference deficiency written under Tag A1101

Based on interview, it was determined that the hospital did not have processes in place to ensure integration with other departments of the hospital, specifically the Urgent Care Clinic. The hospital's failure resulted in a lack of a written policy and procedure regarding how patients from the Urgent Care Clinic were referred to the hospital's Emergency Department.

Findings include:


On 5/25/2016, at 11:30 AM, the ED Medical Director was asked to describe the process for referrals from the Urgent Care Clinic to the ED. The Medical Director stated that the process was for the physician in the Urgent Care Clinic to call the ED physician directly to discuss the patient's referral.

On 5/25/2016, a staff physician in the ED was asked to describe the process for referrals from the Urgent Care Clinic to the ED. The physician described the same process as the Medical Director.

On 5/25/2016, the Clinical Director for ED Services stated that the hospital did not have a written policy and procedure for referral to the hospital's ED. The Director acknowledged that such a policy would provide clinic staff with guidance on appropriate transport of patients from the Urgent Care Clinic, including method of transfer and safety measures to be taken, as well as assist the ED with triage of patients.

Based on interview and review of hospital documents, it was determined that the hospital failed to assure that the Emergency Department (ED) supervised by a qualified member of the medical staff. The hospital's failure to do so resulted in the Governing Body not determining which members of the medical staff were qualified to supervise in the ED.

Reference deficiency written under Tag A1101

Findings include:

On May 24, 2016, at 1:30 PM, the Director of Medical Staff Services was interviewed and asked to provide documentation that the medical staff had defined the qualifications of medical staff. The Director was unable to provide that documentation.

The Director was asked to provide a copy of the job description and was unable to provide that documentation. The Director provided a portion,pages 4 & 5, of the contract between the contracting physician's group and the hospital, which outlined job duties. The document did not specify the name of the hospital; did not specify what board-certification the medical director must have, or if board certification was required, and did not specify the amount, or type, of experience the medical director must have. The document did not have a date the job description was effective, when the document would be reviewed, or a signature.

The Medical Director was interviewed on May 24, 2016 and stated that s/he had board certification in Family Medicine (verified by review of the physician's credentialing file). The Medical Director stated that the hospital accepted physicians who were board-certified in either Family Medicine or Emergency Medicine, and there was one ED physician who was board-certified in Internal Medicine and had been "grandfathered" in.

The Medical Director provided an extensive description of how ED physicians were supervised and how quality assurance processes were carried out; however, the Medical Staff had not defined the required qualifications for the Medical Director.