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Based on record review and interviews, the facility failed to ensure that the patient or representative who submitted a written grievance, received a written response to their grievance within 30 days as specified in the facility's policy for 11 of 14 sampled patients.
(#3, #11, #12, #14, #15, #16, #17, #18, #21, #22, and #23)

Findings include:

Review of the facility's Policy and Procedure for Patient Rights dated 5/26/2015 reveals the following:
1) All grievances require a written response and must include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
2) Every effort will be made to resolve the grievance within 10 business days. If a grievance cannot be resolved within 10 business days, the patient or his/her representative will be provided with a targeted date for resolution and a reason for the delay.
3) Written resolution will be provided to the patient or his/her representative within 30 days from the date on which the grievance process was initiated.
4) The person resolving the grievance shall be responsible for providing a written notice to the patient or his/her representative and ensure that a copy of the correspondence is provided to the Vice President of Risk Management .
A review of the 14 sampled grievances revealed the following discrepancies in 11 of the 14:
#3 Grievance 5/25/16, no oral or written response to the patient as of 7/26/16.
#11 Grievance 4/18/16, no oral or written response to the patient as of 7/26/16.
#12 Grievance 6/20/16, no response oral or written to the patient as of 7/26/16.
# 14 Grievance 4/5/16, no oral or written response to the patient as of 7/26/16.
# 15 Grievance 3/3/16, Written response to the patient guardian on 4/27/16, fifty eight days after grievance.
# 16 Grievance 2/26/16, no oral or written response to the patient as of 7/26/16 .
#17 Grievance 2/21/16, no oral or written response to the patient as of 7/26/16.
#18 Grievance 2/15/16, no oral or written response to the patient as of 7/26/16.
#21 Grievance 4/12/16, written response to the patient 4/25/16, but no notice of delay by 4/22/16.
#22 Grievance 3/1/16, no oral or written response to the patient as of 7/26/16.
#23 Grievance 3/28/16, no oral or written response to the patient as of 7/26/16.
A side by side review of the sampled grievances with the Risk Manager on 7/26/16 was conducted at 2:50 PM . The Risk Manager stated, the previous Risk Manager informed her that she would be responsible for completing the response letters to grievances and had apparently failed to do so. The Vice President of Quality confirmed that the facility had been entering the Grievances into the Incident Reporting System, but had failed to ensure that a response was written and mailed to the patient or responsible party in accordance with facility policy.

Based on record review and interviews, the facility failed to ensure that 2 of 55 Emergency Room Physician's maintained current board certification (#11, # 39) and that 3 of 55 Emergency Room Physician's maintained current certification in Advanced Cardiovascular Life Support (ACLS) or Pediatric Advanced Life Support (PALS) (#15, #21, #48).

Findings include:

1) A review of the delineation of Medical Staff Privileges, Emergency Medicine dated 2014 reveals, applicants can be Type 1, Board eligibility by the American Board of Emergency Medicine; Type 2, Successful completion of an accredited residency in Emergency Medicine or Type 3 Training and experience in Emergency Medicine or a related specialty sufficient to evaluate and initially manage and treat patients who seek emergency care. General privileges include Cardiopulmonary Resuscitation ( Current ACLS required).
Review of the Bylaws of the Medical Staff dated 2014 revealed, the following requirements for appointment to the Medical Staff: Initial appointment to the Medical staff shall be on a provisional basis for not less than a period of one (1) year. Members desiring reappointment must be able to provide evidence of current clinical competency at the time of requesting reappointment to the medical staff. Categories of the Medical Staff including Active, Consultant, Courtesy, Affiliate, Teaching Faculty and Honorary.
Review of the Delineation of Privileges for the Pediatric Emergency Department include the following:
Category I: routine general pediatric care of children with complex or severe illness result in skills acquired in pediatric training sufficient for Board Eligibility/certifications.
Category 2 Illness or problem requiring expertise or techniques acquired during pediatric subspecialty training. (Requires completion of an approved Fellowship program and attestation regarding current clinical competency, Pediatric emergency medicine, Pediatrics
(Emergency Room Physician).
Pediatric Emergency Department Requirements:
Type 1 Board eligibility or certification by the American Board of Pediatric Emergency Medicine.
Type 2 Successful completion of an accredited residence in Pediatric Emergency Medicine
Type 3 Training and experience in Pediatric Emergency Medicine or the Pediatric Emergency Room sufficient to evaluate and initially manage and treat patients who seek emergency care.
Documentation of certification for Cardiopulmonary resuscitation child/ adolescent PALS and /or ACLS.
The sample of active status Emergency Room Physician credential files revealed the following discrepancies;
1) Physician # 15 ACLS Certification expired on 4/1/16.
2) Physician # 21 no evidence of ACLS or PALS certification.
3) Physician # 11's Board Certification in Emergency Medicine expired on 12/31/15.
4) Physician #39 Pediatric Board Certification expired on 12/13/14.
5) Physician #48 did not have evidence of PALS certification.
An interview was conducted with the Medical Director of Quality Organizational Effectiveness (Medical Staff Director), the Vice President of Medical Affairs, the Credentialing Coordinator and the Vice President of Quality on 7/6/16 at 1:00 PM. The Credentialing coordinator was asked to describe the credentials required of a physician to practice in the Ermegency Department. She stated, "have to be either Board Certified in Emergency Medicine at the time of appointment, or if Board Eligible must be Board Certtified within 5 years. The Pediatricians have to be Board Certified or Board Eligible at the time of appointment as well. The Pediatricians must maintain current PALS certification. Currently we do not require recertification as this is under review by the medical staff. It has not been officially changed in the requirements for privileges yet. The electronic system shows us the type of document that is going to expire within 30 days such as their ACLS, license, PALS and the list goes to the Physician by email. Our new Physician tracking system will go live on 7/15/16. We used to have a paper system and we have uploaded it to the new electronic system."
The Medical Staff Director stated, "all Emergency Physician's must have current ACLS cetifications and the Pediatricians must be PALS certified. The Director reviewed the Credential file for Physician # 15 and confirmed that her ACLS certification expired in 4/2016 although she was still listed as an Active Provisional physician. The Director then placed a Text message to Physician # 21, who responded, " He did not have to maintain current ACLS certification in New Jersey and didn't know he had to maintain it in Florida." The Medical Director could not say why this physician was granted Emergency Medicine privileges without the required evidence of either ACLS or PALS certification.

The Medical Staff Director was unaware that 3 of the Emergency Physicians with active privileges had expired ACLS certification and that the Board Certification of # 11 had expired in 2015. The Medical Director confirmed that the five identified physicians did not meet facility criteria as Qualified Medical Staff for the Emergency Department and that the facility failed to ensure that the credentials requirements were met.