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Based on observation, policy review, review of the hospital's complaint log, and staff interview, the hospital failed to ensure 4 of 17 sampled patients (#3, #17, #18, and #19) received written notices in response to their grievance that included the steps the hospital took to investigate the case and notification of the results of the investigation.

Findings:

A review of the hospital's "Complaint Management" policy review/revised on 10/07/09, was completed on 11/04/10. The review revealed the manager/unit director is to make initial contact with the complainant within three business days and "every effort should be made to complete the investigation and resolve the complaint within 14 days." The policy does not define what "resolve" means and does not direct the hospital to provide complainants with a written notice that contains the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

A review of the hospital's "Grievance" policy as reviewed/revised on 12/03/09, was completed on 11/04/10. The review revealed hospital risk managers "will formally acknowledge receipt of a patient's grievance in writing within 5 working days with notice that attempts will be made to resolve their grievance within 60 days." The policy does not define what "resolve" means and does not direct the hospital to provide complainants with a written notice that contains the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

A review of Patient #3's clinical record was completed on 11/04/10. The review revealed the patient presented to the emergency room on 04/01/10 at 11:37 P.M. with a chief complaint of vaginal bleeding for two hours prior to arrival. Her vital signs on arrival were documented in the clinical record as a pulse of 72 beats per minute, respirations of 18 breathes per minute, and blood pressure of 130/72 millimeters mercury. The clinical record review revealed a nursing note dated 04/01/10 at 11:43 P.M. that stated the patient said she had had an ultrasound.

Further review of Patient #3's clinical record revealed a physician's note dated 04/02/10 at 12:16 A.M. that stated she was approximately eight to nine weeks pregnant based on her last menstrual period. The note reiterated that she said she had an ultrasound and that it showed an intrauterine pregnancy with a good heartbeat and that she was having vaginal bleeding.

A review of Patient #3's complaint file was completed on 11/04/10. The complaint file indicated the hospital had received Patient #3's letter of complaint (dated 05/12/10) on 05/20/10, which documented her complaint about not having received an ultrasound. Further review of the complaint file revealed a letter was sent to the complainant on 05/25/10 and a letter dated 08/03/10 was sent to the Specified Patient stating that, "It has been determined that the care provided was appropriate ...".

A review of the grievance committee meeting minutes, completed on 11/04/10, revealed, "The patient called the R(isk) M(anagement) office on 08/05/10 and left a message she was still upset." Neither the file nor the minutes had documentation of Patient #3's call and what the patient was still upset about; nor did the file contain documentation that the patient received a letter describing the outcome of the grievance committee's deliberations.

A review of the hospital's complaint log for April 2010 was completed on 11/04/10. The review revealed Patient #17 complained on 04/09/10 that she was eight and a half months pregnant and was put in a triage room for two hours. She complained she did not have access to a nurse call light and that no one had come to check on her. The log documented the hospital unsuccessfully attempted to call the patient on 04/12/10, and a letter was sent on 04/20/10.
The log did not indicate whether resolution was reached with the patient or whether a letter containing the steps and results of their investigation was sent.

A review of the hospital's complaint log for April 2010 revealed Patient #18 complained on 04/21/10 about his/her spouse being placed in a room in the triage area without anyone available to help him/her. The log stated, "(Patient) ended up urinating in a trash can because they were not informed on anything such as location of bed pan." The log indicated the patient was contacted and apologies were made. The log did not indicate whether a letter containing the steps and results of their investigation was ever sent.

A review of the complaint log for 07/01/10 to 07/10/10 was completed on 11/04/10. The review revealed Patient #19 complained on 07/06/19 about having a roommate that screamed the entire night. The log stated, "It was miserable". The log stated, "When I talked to the nurses, they talked to the head nurse who said there was nothing they could do, but there was a couch in the lobby of my floor that I could put a blanket on if I wanted to sleep there." The log indicated the hospital attempted to call the patient without success. The log did not indicate whether a letter containing the steps and results of their investigation was sent to the patient.

On 11/04/10 at 10:54 A.M. during a tour of the emergency room's triage area, two areas were observed that the nurses use to triage patients and one area for electrocardiogram testing. No call lights were observed in these three areas. This observation was confirmed by Staff C and Staff H during the tour.

On 11/03/10 at 8:30 A.M., in an interview, Staff G confirmed he/she did not know exactly what Patient #3's phone call of 08/05/10 was about, except to say Patient #3 was still dissatisfied. Staff G confirmed no additional communication was attempted with Patient #3, either verbally or in writing because the patient had complained to the local media. As pertaining to Patient
#17, #18, and #19, Staff G confirmed letters containing the results of the hospital's investigation were not sent to the patients.


This substantiates complaint OH00057485.

Based on clinical record review, staff interview, and policy review; the hospital failed to ensure that all patients being seen in the Emergency Department were questioned regarding advance directives. This affected 17 out of 17 clinical records reviewed in the emergency department (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17). The current census of the emergency department was 44 patients.

Findings include:

The clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17 were reviewed on 11/02/10 and 11/03/10. All 17 clinical records lacked documentation of whether or not these patients had executed advance directives.

Staff C, D, and F were interviewed on 11/02/10 at 2:53 PM. Staff D stated that patients were not asked about advanced directives until they were admitted to the hospital and that it was not a requirement for outpatient areas to ask about advance directives; and the emergency room was considered an outpatient area. Staff D also stated that any patient seen in and discharged from the emergency room would not be asked about advanced directives. Staff F stated that the registration personnel obtained demographic information, emergency contact information, consent for treatment, and provide insurance based information to each patient seen in the emergency department. If a patient requested information regarding advanced directives, information would be given. If a patient mentions advanced directives, the registration personnel would direct the patient who they should speak to regarding advance directives. Staff D stated that if a patient's condition warranted, pastoral care or the physician would initiate a conversation with the patient and family regarding advance directives. Staff D also stated that ambulance attendants would "pass on" information regarding advance directives if they were aware of any.

The hospital's "Advance Directives: Durable Power of Attorney for Healthcare and Living Wills" policy was reviewed on 11/03/10. The policy stated that during the admission process, the clinician will ask the patient if he/she had an advance directive and will record the patient's answer. The policy also stated that in ambulatory departments of the hospital, upon request by the patient, the patient will be given information regarding advance directives and how to formulate the advance directive.

At 11:14 AM on 11/04/10, Staff A, D, and E were interviewed regarding advance directives. Staff D stated again that asking patients about advance directives was not a requirement for outpatient settings. Staff D stated the standard of practice in emergency departments was not asking about advance directives. Staff D stated that if a patient were to have a cardiac arrest in the emergency department, they would be resuscitated unless a family member spoke up and informed the emergency department that the patient had advance directives. If the emergency room was aware of advance directives, they would be honored while the patient was in the emergency department.