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Based on review of hospital policies/procedures, documents and interview with staff, it was determined that the administrator failed to require that provide the patient a written notice of it decision with in seven days of receipt of a grievance.

Findings include:

Review of the facility policy and procedure, Patient Complaint, Discrimination and Grievance revealed: "...Complaint Coordinator will conduct internal investigation, submit a report of findings and implement corrective actions...Within seven (7) working days of receipt of the Grievance, provide each patient...written notice of its decision...."

Patient # 1: Review of the facility Managerial Investigation revealed that the complaint was lodged on September 04, 2009, a letter dated September 28, 2009, to the patient regarding the investigation was sent via Certified Mail on October 02, 2009, and returned undelivered October 06, 2009. The letter was resent via Certified Mail with the updated address on December 07, 2009.

Patient #2: Review of the facility Managerial Investigation revealed that the complaint was lodged with the hospital on 9/1/09. The facility sent a certified letter to the patient on 9/15/09. The patient claimed that certified letter on 9/24/09.

The CNO confirmed on interview that neither patient was notified within the 7 working days as required by facility policy and procedure.

Based on review of facility policies and procedures, documents, the medical record, and interview, it was determined that administrator failed to require that a patient who had received pain medication be transported to the CT scanner by wheelchair or stretcher.

Findings include:

Review of the Emergency Department Intake Guidelines revealed that after the Intake process is complete the patient may be placed in the Continuing Care area (waiting room). No intravenous (IV) narcotics or other medications can be given in this area that may significantly affect the patient's vital signs or level of consciousness.

Review of Patient #2's medical record revealed that at 2023 hours an assessment of the patient's pain was documented as 8 on a scale of 1 to 10, with 1 being the lowest and 10 being the highest. Morphine 4 milligrams was given intramuscularly as ordered for pain. The patient experienced partial relief with the assessed level of pain of 6 at 2336 hours. An IV saline lock was inserted which was used to administer contrast for the Computerized tomography (CT).

The medical record indicates that the patient went to the CT room for a scan, but there is no documentation that the patient was assessed for balance/dizziness nor was there documentation as to the mode of transportation.

On interview the Clinical Director confirmed that the CT technicians usually transport the patient from Continuing Care to the CT room which is contiguous with the ED.

Review of a memo from the CT supervisor dated 5/12/2009, revealed: "...All ED patients must be transported to the CT via wheelchair or gurney. They cannot walk over...."

On interview the CT Scan Supervisor confirmed that the CT technicians are responsible to transport ED patients to the CT Scan room. The patient received Morphine in the waiting area. There is no documentation to indicate the method of transport.