HospitalInspections.org

Based on medical record review, document reviews, and staff interviews, it was determined the facility failed to follow policy and procedures for filing and responding to a grievance, in one (1) out of one (1) patient elopement, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was presented to the facility's Emergency Department (ED) on 10/24/23 at 10:34 p.m. accompanied by the Police Department. A "Note" by Employee (emp) #3 on 11/01/23 at 4:42 p.m. states, "Paging service to notify of patient escaped unit and was found off of Hospital property by security." A "Discharge Summary'' on 11/01/23 at 5:12 p.m. by emp #4 states in part, " ... Today pt eloped without notifying nurse or physician team of [patient #1] intentions or concerns about leaving. No one was able to counsel [patient #1] or redirect [patient #1] to stay in the hospital. Per unit, pt was spotted off of Hospital property and security is not able to apprehend at this stage. Security notified the local authorities that the patient is missing. [HCS (Healthcare Surrogate)] was notified of patient's elopement." A "Note" by emp #5 on 11/01/23 at 5:31 p.m. states, "Informed by care manager [emp #1] that patient had eloped. Call approximately 425p [4:25 p.m.] Simultaneously heard overhead page for this patient's elopement during call. Later 443p [4:43 p.m.] [Emp #1] called again. Informed security reported patient had been off property, and they were not permitted to force patient to return since [patient #1] was no longer on Hospital property per report. [Emp #1] unsure if security had contacted police. I contacted security dispatch. Spoke to an officer [emp #6]. Explained the patient lacks DMC and was a ward of the state. [Emp #6] stated [emp #6] would call local police. I contacted [HCS] to informed [HCS] of elopement. I informed [HCS] security reported they would now call police. Reportedly, the patient was last seen a little past the Varsity Club on Willowdale Rd [Road] per security."

Emp #6 gave the following written statement regarding patient #1, "I was able to review video footage and find patient [patient #1] exiting the main Ruby visiting elevators at approximately 16 :20:19 [4:20:19 p.m.] hours. The patient then exited the Ruby main canopy @ [at] approximately 16:21:09 [4:21:09 p.m.] hours and made [patient #1's] way through the C-lot [parking area] and onto University property at approximately 16:24:37 [4:24:37 p.m.] hours. The initial phone call from the staff from 7 West came in at approximately 16:24:49 [4:24:49 p.m.] hours and was immediately given out to the officers. At approximately 16:25:01 [4:25:01 p.m.] the officers at the main canopy of Children's Hospital located the patient as [patient #1] made [patient #1's] way up the service road to the stadium and cut across the F 3-4 [parking area] lot where [patient #1] then exited the lot and crossed Willowdale Road at approximately 16:29:46 [4:29:46 p.m.]. Due to the patient leaving hospital property, law enforcement was notified. Officers were never able to make contact with the patient."

A policy was reviewed titled, "Patient Complaints and Grievances," last revised 08/14/23. The policy states in part, "... Definitions: ... Grievance - A Formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding that patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with CMS Patient's Rights CoPs [Conditions of Participation], or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 ... Procedure: ... Once a grievance has been filed, a patient advocate, or designee, will respond to the complaint in writing, within seven [7] calendar days. This written response shall, at a minimum, acknowledge the patient's concerns. If the resolution will take longer than seven [7] days, the acknowledgment letter will inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will include the current progress and the time frame for future updates. WVUHS [West Virginia University Health System] strives to resolve all grievances as soon as possible. Steps in the grievance investigation process include, but are not limited to interviewing the patient, interviewing the complainant (if different than the patient), reviewing relevant medical records, interviewing staff with potential knowledge of the situation, researching applicable laws, regulations, policies, and procedures, identifying measures, including those already taken, to resolve the problem ..."

The Grievance/Complaint Log, titled "OFLAC Report" was reviewed for 11/01/23 through the present. The event involving patient #1's elopement was not listed on the log.

A review of the policy, titled "Abuse and Neglect of Incapacitated Adults and Facility Residents," reviewed 12/21/21. The policy states, in pertinent part, "... Procedure: ... B. Reporting Mechanism 1. Reporting Responsibility: Any medical, dental or mental health professional or social service worker who has reasonable cause to believe that an incapacitated adult or facility resident is, or has been neglected, abused or placed in an emergency situation, or who observes an incapacitated adult or facility resident being subjected to conditions that are likely to result in abuse, neglect or an emergency situation must immediately report the circumstances by telephone to the WV Abuse and neglect hotline at 1-800-352-6513. The telephone report must be followed by a written report within 48 [forty-eight] hours. The reporter may request that [patient #1] or her name be removed from the report before APS forwards it to the appropriate law enforcement agency, prosecuting attorney, or medical examiner. The Care Management Department can assist with facilitating this process ..."

An interview was conducted with emp #9 on 11/06/23 at 12:40 p.m. Regarding the incident with patient #1, emp #9 states, "I was present when this happened. I had seen this patient right before 4:00 p.m. that day. After the incident we had discussed it in Daily shift huddles. I had not been asked to do any formal investigation into the incident yet."

An interview was conducted with emp #1 and emp #5 on 11/06/23 at 12:50 p.m. Emp #5 explained that [emp #5] filed the APS due to the fact that the patient was incapacitated and was going to be out in cold weather. "The team made the decision to file the APS the next day. The decision was made since the APS form stated that any incapacitated adult that could be at risk, you should file an APS. The intent was not to allege neglect against the hospital."

An interview was conducted with emp #12 on 11/06/23 at 3:22 p.m. Emp #12 confirmed an incident report was filed in the Event Monitoring System (EMS) on 11/01/23. An investigation began on 11/01/23 and was still in process. The event was not considered a grievance.

An interview was conducted with emp #13 and emp #14 on 11/07/23 at 8:51 a.m. Regarding the incident of patient #1 eloping, emp #13 and #14 state, "We look at the incident log first thing in the morning. We would have received this on 11/2. We start fact finding and working with events that could be a sentinel event. The fact-finding process begins the process. We start with the medical record and create a timeline of events. We reach out to the leadership afterwards to get additional details. When we reach out to leadership, we try to have some sort of resolution by the end of the day. There's no resolution yet to this as we are still in the fact-finding process. Ideally, we would complete our investigation in less than forty-five (45) days. We usually have thirty (30) events per day that need to be investigated and we have two (2) coordinators that review the events. If an event needs to be immediately investigated, leadership or Administration would let us know. Otherwise, all events go through the same process."

A telephone interview was conducted with emp #19 on 11/08/23 at 10:26 a.m. Regarding the incident involving patient #1 eloping, emp #19 states in part, "I felt that no immediate intervention or investigation was necessary as did the chief quality officer. We did not report this as a grievance as there was no indication of neglect on the part of the staff."