HospitalInspections.org

Based on interview and record review it was determined the facility failed to implement hospital policy "Patient Grievance Process" for 1 of 5 sample patients, (Patient 5).

Findings include:

During the survey it was determined that the hospital had a specific policy and procedure regarding complaints about patient care. Those procedures are outlined in hospital policy "Patient Grievance Process" and indicate that the hospital will initiate a grievance process whenever a complaint is received. Interview and record review revealed that the hospital failed to implement such procedures following a complaint regarding the care of Patient 5 in the Emergency Department (ED) on 2/20/13.

Hospital records indicate that Patient 5 had been admitted to the hospital Emergency Department (ED) on 2/20/13 at 11:29 am. Those records further indicate that Patient 5 had been treated, and following observation, was discharged home at 3:50 pm via ambulance.

Ambulance records of 2/20/13 reflect that Patient 5 was transported from the hospital to home and discharged into the care of Witness B. In interview on 4/21/13 at 10:20 am Witness B indicated that he/she had been present when Patient 5 was brought home that day. Witness B further stated that they had been so upset about Patient 5's condition that they had called the hospital to complain about his/her care.

In interview on 4/21 Witness B indicated that he/she had called the hospital on 2/20/13 at approximately 7:00 pm, and had talked to Employee 4. Witness B reported that he/she had asked to talk to Employee 3, but was told he was not available.

Witness B stated that he/she had complained to Employee 4 about Patient 5's care, and that Witness E and F had witnessed the call. Written records of 2/20/13 from Witness E and F verify that such a call had occurred.

Interview of hospital staff and review of facility records reveal no evidence that a complaint regarding Patient 5's care in the Emergency Department (ED) on 2/20/13 had been received. According to Employee 2, no grievance process had been initiated. According to Employee 6, Employee 4 had stated to them that he/she had no recollection of such an event.

The hospital failed to initiate hospital policy "Patient Grievance Process" regarding the care of Patient 5 in the ED on 2/20/13.

Based on interview and record review it was determined the hospital failed to implement Emergency Department policy "Discharge from the ED," for 1 of 5 sampled patients (Patient 5).

Findings include:

Hospital records indicate that Patient 5 had been admitted to the hospital Emergency Department (ED) on 2/20/13 at 11:29 am. Those records further indicate that Patient 5 had been treated and following observation, was discharged home at 3:50 pm via ambulance.

Hospital Emergency Department policy "Discharge from the ED" includes specific procedures that are to be implemented at the time of a patient's discharge from the ED. Those procedures include the provision of discharge instructions. Interview and record review revealed the hospital failed to implement those ED policies at the time of Patient 5's discharge.

According to hospital policy, discharge instructions are to be provided to the patient or patient representative, and they are to "sign the
Discharge instructions with the signature witnessed." Furthermore, "the ED record will identify whether the discharge instruction were given.... and that the patient or significant other understood the discharge instructions."

Review of Patient 5's medical record of 2/20/13 revealed no documented record that Patient 5 had been provided discharge instructions. There was no evidence that discharge instructions were provided to the patient or patient representative, or that "the ED record will identify whether the discharge instruction were given.... and that the patient or significant other understood the discharge instructions."

The hospital failed to implement hospital policy "Discharge from the ED" following Patient 5's care in the ED on 2/20/13.