HospitalInspections.org

Based on hospital policy review, medical record review, grievance log, email correspondence, and staff interviews, the hospital staff failed to ensure prompt resolution of a grievance for 1 of 1 post surgical patients (Patient #6).

The findings include:

Review on 05/03/2016 of hospital policy "Patient Grievance Management" reviewed/revised 11/2015 revealed "Summary Statement: This policy sets forth the procedure for appropriately identifying and promptly resolving patient grievances...Procedure...7. Within seven calendar days, the patient or complainant will be sent a follow-up letter by the appropriate administrator, or designee which addresses a resolution or notifies the patient that further investigation is required. The patient or complainant will be informed of an expected follow-up time to address the resolution and will be kept informed of the progress on a weekly basis. All grievances will be resolved as soon as possible with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 days. 8...the administrator, or designee will provide the patient or complainant with written notice of the decision, the name of the appropriate contact person, the steps taken to investigate, the results of the grievance process, and the date of completion..."

Closed medical record review on 05/03/2016 revealed Pt. #6 (named patient) was an 81 year old y.o. male with a history of gastric cancer (stomach cancer), arthritis, high cholesterol, weight loss, and gastroesophageal reflux (GERD) presented to the hospital on 11/24/2015 at 0700 for a scheduled surgical intervention as treatment for a recently diagnosed adenocarcinoma (cancer) of the stomach. Review revealed Patient #6 underwent surgery on 11/24/2015 at 0914 for a Vagotomy (procedure performed to reduce gastric secretion) and Hemigastrectomy (resection of the nerve from the brain) with noted difficulty with placement of the nasogastric tube (NG-tube: nasal tube). Review revealed the patient had post-surgical (after surgery) confusion, pulled the NG-tube which subsequently cleared. Review revealed while on Post-Surgical Unit I, the patient experienced changes in cardiac rate and rhythm with noted rates of 120's and was transferred to the Progressive Cardiac Care Unit (PCCU) on 11/28/2016 at 90042 for continued treatment and stabilization. The named patient was noted with "runs of SVT (superventricular tachycardia: fast heart rate (HR)), BP 85/60." Review of surgeon note on 11/27/2015 at 1149 revealed the patient "complained of (c/o) hunger" and tube feedings were started while awaiting return of bowel function." Review of nursing note on 11/27/2015 at 1400 revealed tube feedings were started with "no complications" noted. Review of cardiology note on 11/29/2015 at 0852 revealed the patient continued to experience fluctuations in HR with no adverse effects noted. Continued review of the medical record revealed nursing staff reported each increase in HR or change in BP. Review of nursing note on 11/29/2015 at 0730 revealed NG-tube feedings continued to infuse without noted difficulties breathing or complaints with clear "lung sounds." Review of the nursing note on 11/29/2015 at 1400 revealed the patient began demonstrating agitation earlier in the shift and Ativan was administered. Review of the same note revealed at 1405 the patient's agitation continued, he "began vomiting bile," the nurse called for assistance and suction, there was no pulse, and a Code Blue (used for cardiac arrest) was called 11/29/2015 at 1414, chest compressions began with assisted ventilation noted at 1416, hospitalist notification with code team arrival at 1416. Review revealed the patient was intubated at 1424, pulse obtained at 1426, with a BP of 99/72 noted. The patient was transferred to CCU (Critical Care Unit) at 1430. Review revealed the patient remained on the ventilator (breathing machine), continued to decompensate over the course of the day, and expired 11/29/2115 at 1954.
Review on 05/04/2016 of the hospital's grievance log revealed Patient #6's name was added to the log on 02/10/2016 with a noted date of incident was 11/29/2015. Continued review of hospital documentation revealed there was no grievance file created for the family complaints or information gathered during the investigative process.
Review on 05/04/2016 of email correspondence to the hospital's Customer Care Line revealed a letter indicating the family was told on 11/29/2015 following the patient's death, they would be contacted the next day for further discussion of events surrounding the unanticipated death. Review revealed on 12/10/2015, family again reached out to the hospital and spoke with (Staff #5 and 9) and was "assured that I would get a call from (Staff #4) within five days after completion of her investigation." Further review of the same email correspondence revealed the hospital's chief executive officer (CEO) was put "on notice" of the situation at 1113 that same day. Review revealed Staff #6 contacted the family member on 12/10/2015 and was "working on her issues."
Interview on 05/04/2016 at 0900 during a meeting with Staff #12, 13, 11, 6, 4, 10, 9, and 5 revealed the family's concerns were considered a "formal grievance" but a grievance file was not created. Interview revealed concerns raised in the grievance were taken seriously and addressed as quickly as possible. After case reviews and interviews with staff and family, it was decided no further action was indicated. Interview revealed Staff #6 made two attempts to contact family members and left voice messages. Interview with Staff #4 revealed a letter should have been sent to the family following the investigation explaining what measures the hospital had taken to investigate the concerns and the outcome of the investigation as outlined in the hospital's "Patient Grievance Management" policy.

NC00116200