HospitalInspections.org

Based on policy review, record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 1 (#2) of 2 patients reviewed for complaints/grievances from a total patient sample of 3 (#1, #2, #3).
Findings:

Review of the hospital's Occurrence Reporting Procedures policy revealed in part: 1. Actual event - when something happens that is unexpected and undesirable ... Reportable events involving injury or potential injury to patients or visitors may include, but are not limited to: ...patient leaving AMA (Against Medical Advice) or elopement ...

Review of the hospital's Policy and Procedure for Customer Comments, Complaints and Grievances revealed in part: A grievance is defined as a formal written, or verbal complaint that is made to the facility by a patient, visitor, or support person (when the complaint is not resolved at the time of the complaint by staff present) ... Guidelines-Staff Receives Complaint - Document all pertinent information in the on-line reporting system: Feedback Manager.
Processing Grievances - If a complaint cannot be resolved immediately by staff present, it becomes a grievance and follows the grievance process. The complaint will be flagged as a grievance in the online reporting system, Feedback Manager.
Grievance Resolution - A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf.

Review of Patient #2's medical record revealed in part: date of birth 01/05/2018. Admit 06/19/2024 with diagnoses of nausea, vomiting and diarrhea. The patient has a history of bowel intussusception, and small bowel obstruction.

History and Physical not completed. Patient left AMA.

Discharge Summary - Patient left AMA with parents before being seen.

Nursing Notes dated 06/20/2024 at 07:00 - Patient's mom voiced concern regarding patient's care. Mom stated if S1Physician was not available, she would like to go to Hospital B. Nurse informed patient's mother that S1Physician was not on call today. Charge nurse and house supervisor made aware. S2Physician notified. Parents do not want patient to be transferred, they will discharge out. Nursing unable to convince mother to keep patient inpatient or to wait and see S2Physician. Mother states they are leaving and going straight to Hospital B Emergency Room. 07:52 a.m. Call to S2Physician. 7:55 a.m. Nurse spoke with mother and relayed S2Physician wanted patient transfer via ambulance. Mother still states she wants to leave and is going immediately to Hospital B.

Review of the hospital's patient discharge list for June 2024 revealed Patient #2 was discharged 06/20/2024 with a discharge disposition listed as "AMA".

Review of the hospital's Occurrence Reporting Logs and the hospital's Grievance Logs failed to reveal Patient #2.

In an interview on 07/02/2024 at 12:05 p.m., S3SVP Quality acknowledged an Occurrence Report was not made and stated this occurrence was a reportable event and would have been identified as a grievance if the occurrence was reported according to policy.