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Based on medical record, document review and staff interview, the hospital failed to ensure grievances were reviewed and resolved for (Patient #1 and #4). A total of six grievances were reviewed. The hospital census at the time of the survey was 60.

Findings included:

The facility policy regarding complaint and grievances was reviewed on 06/03/11. No policy number is listed. The policy defined a grievance as; any formal expression of dissatisfaction with a real or perceived violation of patient rights, patient abuse or neglect, patient harm, hospital compliance with regulatory requirements that requires committee review in which the intent is to evaluate and indicate any process improvement related to patient care. The policy went on to say the patient relations department in conjunction with the department leadership will be involved in finding solutions as quickly as possible and request assistance from other departments and resources as necessary. Documentation should include, ...resolution of the grievance and date of completion. Once a grievance is received, the patient relations department must respond to the patient within seven days with information that their grievance was received and the decision if the hospital has resolution. If resolution is not achieved in seven days, the patient must still be informed in writing of the continuing investigation. The policy also included detailed information regarding what is to be included in the written response.


The emergency record for Patient #1 was reviewed on 06/01/11. The patient was seen in the emergency department on 04/26/11 with right leg pain and triaged by the nurse with positive DVT (deep vein thrombosis) of the right leg. Review of the grievance log of the hospital revealed the patient complained about his/her care to the patient relations department. The documentation of this grievance stated; "patient came to ER Tuesday 04/26/11 -referred by her physician. She is terminally ill with invasive uterine cancer-had severe pain with blood clots. She was very offended that the discharge papers said she had "narcotic -seeking behavior. She stated she is not narcotic -seeking, she is just trying to get some relief for her pain."

Further review of the documentation regarding this grievance lacked documented evidence the hospital investigated this complaint, took any steps toward resolution, or notified the patient of the outcome of this grievance.

The medical record for Patient #4 revealed the patient phoned the patient relations department on 04/04/11 and "asked for a visit". The patient stated he/she did not feel his/her pain was managed adequately. The documentation revealed a representative spoke with Physician BB to see if the patient's discharge could be reversed as he/she did not feel ready. Physician BB stated this was "not a good idea." The patient was then told he would be discharged, but could stay until he saw a pain specialist that evening. "with the hope that (pain specialist) will let him know how he can help him with pian management". The medical record lacked evidence the pain specialist ever examined the patient. The patient was sent home with prescriptions for pain management from the treating physician with the agreement of the pain specialist.

The documentation stated, "Because patient was discharged, can be closed." The documentation lacked evidence any further investigation had been completed in regards to the patient's complaints about the physician being arrogant. No information was documented about what this meant, or what was said or done to give the patient this impression. The documentation lacked evidence the patient had been informed of the resolution of his grievance, since he was still discharged without seeing the pain management specialist, which was his original complaint.

These findings were reviewed in detail with Employee H and I on 06/03/11 at 3:55 P.M. No further documentation was provided as of the time of exit.

Based on medical record, document review and staff interview, the hospital failed to notify patients and/or their family members of the outcome of grievances filed. This affected three of six patients with grievances filed, (Patient #1, #4, and #3). The census at the time of the survey was 60.

Findings included;

The facility policy regarding complaint and grievances was reviewed on 06/03/11. Once a grievance is received, the patient relations department must respond to the patient within seven days with information that their grievance was received and the decision if the hospital has resolution. If resolution is not achieved in seven days, the patient must still be informed in writing of the continuing investigation. The policy also included detailed information regarding what is to be included in the written response. Please refer to A119 for details of the complaint greivance policy.


The emergency room record for Patient #1 was reviewed on 06/01/11. The patient was seen in the emergency department on 04/26/11 with right leg pain and triaged by the nurse with positive DVT (deep vein thrombosis) of the right leg. Review of the grievance log of the hospital revealed the patient complained about his/her care to the patient relations department. Further review of the documentation regarding this grievance lacked evidence the hospital notified the patient of the outcome of this greivance, took any steps toward resolution, or further investigated this complaint.


The medical record for Patient #4 revealed the patient phoned the patient relations department on 04/04/11 and "asked for a visit". The patient stated he/she did not feel his/her pain was managed adequately. The patient was unhappy with the treating physician, stating the physician was arrogant. The patient was to be discharged from the hospital that date. Patient #4 had a history of RSD (Reflex Sympathetic Dystrophy - a pain disorder). The documentation revealed a representative spoke with Physician BB to see if the patient's discharge could be reversed as he/she did not feel ready. Physician BB stated this was "not a good idea." The patient was then told he would be discharged, but could stay until he saw a pain specialist that evening. "with the hope that (pain specialist) will let him know how he can help him with pian management". The medical record lacked evidence the pain specialist ever examined the patient. The patient was sent home with prescriptions for pain management from the treating physician with the agreement of the pain specialist.

The documentation stated, "Because patient was discharged, can be closed." The documentation lacked evidence any further investigation had been completed in regards to the patient's complaints about the physician being arrogant. No information was documented about what this meant, or what was said or done to give the patient this impression. The documentation lacked evidence the patient had been informed of the resolution of his grievance, since he was still discharged without seeing the pain management specialist, which was his original complaint.


The documentation of the complaint reviewed in the hospital's grievance log revealed the daughter/POA of Patient #3 filed a formal complaint with the hospital regarding her father's care in the form of a letter dated 04/27/11. The facility provided the surveyors with a report of the investigation of this complaint, after it was requested on 06/03/11. This report of the investigation lacked resolution or written response to the complainant as of the date of review on 06/03/11. The investigation lacked dates for this investigation. Surveyors were unable to determine if the investigation had been started prior to the surveyors' request.

The complaint letter contained numerous allegations including physicians not respecting the wishes of the daughter/POA regarding the patient's care, not keeping her involved and informed, as well as issues related to the patient's care such as medications not being given and call lights not being answered in a timely manner. The daughter also stated the patient's family was asked to attend a mandatory ethics meeting in which they were told the patient would only be released to a hospice program, contrary to the family's wishes.

The documentation revealed a statement from Physician BB in which he/she denied speaking about end of life care in front of the patient, stating that he/she "was down the hallway in the ER corridor". The note from Physician BB stated the Gastrointestinal specialist "wouldn't even place a feeding tube in this patient because it would not alter or improve his condition". He/she further stated, "Overall, I think we need to remind ourselves that we have to allow people to make their own decisions, even if we disagree. It was quite clear the family wanted everything done and has in my opinion unrealistic expectations for his recovery."

The documentation also included a note from Physician AA. Physician AA stated "If this individual files a formal complaint, please know that I would ask that I and all the other care givers be vigorously defended by the hospital. Furthermore, if necessary, I will make a counter complaint of harassment and libel on the part of (Patient #3's family member) for these incredulous and untrue statements he has made about me and others."

The hospital had no further documentation of the complaint on Patient #3. The documentation lacked inclusion of any interview or discussion with the social worker or the other physician present at the ethics meeting. No documentation was noted in regards to any possible witnesses to the discussion with Physician BB regarding end of life care. The documentation also lacked evidence any of the other complaints regarding Patient #3 were reviewed, including the concerns about the patient's medications, call lights, bed position, notification to the family of the patient's bleeding, the "WOW" label and the appropriateness of moving the patient to the ICU.

This finding substantiated Complaint number OH00060594.

Based on staff interview, clinical record review and review of the hospital patient grievance log, the hospital failed to ensure all medications administered for Patient #1 and #5 and failed to ensure discharge instructions for Patient #2 were correctly evaluated and assessed by the registered nurse. The total census was 60.

Findings include:

The emergency record for Patient #1 was reviewed on 06/01/11. The patient was seen in the emergency department on 04/26/11 with right leg pain and triaged by the nurse with positive dvt (deep vein thrombosis) of the right leg. Review of the complaint log of the hospital revealed a complaint to patient relations regarding the emergency department. Comments section stated: "patient came to ER Tuesday 04/26/11 -referred by her physician. She is terminally ill with invasive uterine cancer-had severe pain with blood clots. She was given an injection of Toradol and found out that this medication should not be given for blood clots."
The medication reconciliation form in the medical record revealed home medications of Fragmin (injectable anticoagulant) 2500 units daily and Coumadin (oral anticoagulant)10 milligram daily. The nurse administered Toradol 30 milligrams to the patient as ordered by the physician at 1:58 P.M. This medication is listed as a non-steroid pain reliever with risk of an increase of cardiovascular thrombosis, myocardial infarction, and may be fatal. The drug inhibits platelet formation and so is therefore contraindicated in patients with a high risk for bleeding. There was no documented evidence in the medical record to indicate the nurse had consulted the physician regarding the home medications nor any documentation written by the physician.



The medical record review for patient #5 was reviewed on 06/02/11. The patient presented to the emergency department of the hospital on 03/10/11 and was admitted to the hospital with a chief complaint of pneumonia and urinary tract infection. A review of the hospital complaint log revealed a complaint entered by the daughter on 04/13/11 to patient relations. The daughter stated the patient was "overdosed ten times the amount ordered for Xanax (antianxiety) for 2 days during the hospital course. Review of the medical record review revealed the medication reconciliation form dated 03/10/11 that included the patient over- the- counter products and prescriptive medications that had been administered to the patient at home. This included the Xanax. This form was then signed by a nurse and the family member on 03/15/11 (date of discharge). This form was listed the medications and "Xanax , dose-2.5 milligrams, route orally and frequency 2 times a day at 2:00 PM and 6:00 PM." The section marked "dose" was 2.5 milligrams with this dose marked out with 0.25 milligrams written down below the 2.5 milligrams dosage. There was no documentation and/ or initials of the person that marked out the dosage and the date when this was marked over. A summary on the patient relations form stated "the only thing I can say from nursing point of view is that if you look at the med rec-it originally said 2.5 milligrams BID (twice a day)- later crossed out (different handwriting) and changed to 0.25 milligrams. Nursing gave 2.5 milligrams on 03/11 at 1:45 and on 03/12 at 1:17 . The max dose daily should not exceed 4 milligrams/day- I do not see where a second dose was given either day- changed after 03/12. My question is "why was med rec incorrect? and also if it was written for BID-why didn't pharmacy question as this exceeds recommended maximum dose (even though I do not see a second dose given either day." A physician's telephone order was written on 03/12/11 at 1615 for "home med clarification- Xanax 0.25 milligrams by mouth at 2:00 PM and 6:00 PM start 03/13/11- hold for lethargy".

Review of the medical record for patient #2 was completed on 06/02/11. The 18 year old patient was brought to the emergency department on 04/13/11 by his father after a rugby accident. The patient had a laceration of the inner lip and the one and one half centimeter wound was sutured with 2 sutures. The discharge instructions were to: (1) sutures will dissolve in next seven to ten days and (2) swish and spit with hydrogen peroxide and with one half water for five days. The discharge instructions lacked evidence of diet instructions. Review of the complaint log revealed the father called complaining and "very upset- asked if his son could eat and the staff said yes. The son went home and while eating a sandwich the sutures had fallen out." The remarks on the 05/19 section by the staff stated "we did not write on discharge that the patient should stay on soft diet."