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Based on interview and record review staff failed to follow hospital procedure for the submission of a complaint expressed by a patient who received services in the Emergency Department. (Patient #2) Findings include:

Per record review on 2/23/10, Patient #2 was brought to the Emergency Department (ED) at 14:44 on 12/30/09 via ambulance for mental health issues. During the course of his stay in the ED, Patient #2 expressed dissatisfaction regarding staff treatment and the disposal of personal medications brought with the patient to the ED. Per review of ED 'Nursing Record ' a staff nurse writes on 12/30/09 at 1850: "Pt. States ' my property was destroyed'. Referring to empty pill bottles. 'I want to file a complaint' ". As per hospital 'Complaint Investigation Process' when ED nursing staff identified they were unable to resolve Patient #2's complaints, the evening supervisor was contacted to perform an initial investigation and speak with Patient #2.

Per interview on 2/22/10 at 4:07 PM the evening nursing supervisor confirmed a meeting transpired with Patient #2. After a brief discussion with Patient #2 the nursing supervisor failed to complete a 'Complaint Investigation Form', as per hospital policy, however did complete an ' Incident Report' form. In addition, the supervisor contacted the ED nurse manager by phone, leaving a message regarding the complaint. Per facility complaint policy, the nurse manager is responsible to "Review and complete an investigation if needed and determine actions to resolve. Follow up with the patient/family and with the nurse who identified the problem as to the steps taken". Per interview on 2/23/10 at 12:52 PM, the ED nurse manager confirmed he/she failed to follow up on information reported by the evening nursing supervisor or conduct a review of the Patient #2's ED record to assess if any further issues or problems required further action.

Per interview on 2/23/10 at 9:05 AM, the Director of Risk Management stated Patient #2 had contacted him/her while still a patient in the ED on 12/30/09. Although an internal investigation was conducted by the Director of Risk Management, the ED nurse manager was not provided a copy of the ' Incident Report ' nor was the nurse manager included in the investigation. The Director of Risk Management stated "Not sure he/she was in the loop" and " No corrective actions " resulted from the investigation.

Per record review, Patient #2's 'Emergency Nursing Record' noted several medications were destroyed including Vicodin, caffeine, Ibuprofen and 14 other unidentified pills. Per interview at 4:30 PM on 2/22/10, the nurse who destroyed the medications stated he/she had received permission from the patient, however there was no note written stating permission was received by Patient #2 nor was there documentation by a witness of the disposal of the medications. Per interview at 10:50 AM on 2/23/10 the Pharmacy Manager stated his department does dispose of patient medications however Pharmacy was not contacted by ED staff to remove the medications and presently there is no written process for the disposal of patient medications in the ED. The Pharmacy Manager stated a more formalized process was needed.

Based on interview and record review, the hospital failed to identify opportunities for improvement in the care delivered to 1 of 10 applicable patients who received Emergency Department Services. (Patient #2) Findings include:


Per interview on 2/23/10 at 12:52 PM, the ED nurse manager confirmed he/she failed to follow up on information reported by the evening nursing supervisor or conduct a review of the Patient #2's ED record to assess if any further issues or problems required further action. Per record review on 2/23/10, Patient #2 was brought to the Emergency Department (ED) at 14:44 on 12/30/09 via ambulance for mental health issues. During the course of his stay in the ED, Patient #2 expressed dissatisfaction regarding staff treatment and the disposal of personal medications brought with the patient to the ED. Per review of ED 'Nursing Record ' a staff nurse writes on 12/30/09 at 1850: "Pt. States ' my property was destroyed'. Referring to empty pill bottles. 'I want to file a complaint' ". As per hospital 'Complaint Investigation Process' when ED nursing staff identified they were unable to resolve the Patient #2's complaints, the evening supervisor was contacted to perform an initial investigation and speak with Patient # 2.

Per interview on 2/22/10 at 4:07 PM the evening nursing supervisor confirmed a meeting transpired with Patient #2. After a brief discussion with Patient #2 the nursing supervisor failed to complete a 'Complaint Investigation Form', as per hospital policy, however did complete an 'Incident Report' form. In addition, the supervisor contacted the ED nurse manager by phone, leaving a message regarding the complaint. Per facility complaint policy, the nurse manager is responsible to "Review and complete an investigation if needed and determine actions to resolve. Follow up with the patient/family and with the nurse who identified the problem as to the steps taken".

Per interview on 2/23/10 at 9:05 AM, the Director of Risk Management stated Patient #2 had contacted he/she while still a patient in the ED on 12/30/09. Although an internal investigation was conducted by the Director of Risk Management, the ED nurse manager was not provided a copy of the ' Incident Report ' nor was the nurse manager included in the investigation. The Director of Risk Management stated "Not sure he/she was in the loop" and " No corrective actions " resulted from the investigation.

However, per review of 'Emergency Nursing Record' the disposal of Patient #2 medications was documented without noting patient's permission was received, how they were disposed and who witnessed the disposal. As a result of the incomplete documentation, the evening supervisor requested the nurse who disposed of the medication to write an addendum in Patient #2's record. Per interview on 2/22/10 at 4:30 PM the nurse who disposed of the medications confirmed the nursing supervisor had contacted them regarding the documentation, however they failed to complete the requested addendum to the record. In addition, because the ED nurse manager failed to investigate the complaint no communication resulted with the hospital Pharmacy. Per interview at 10:50 AM on 2/23/10 the Pharmacy Manager concurred Pharmacy was not contacted by ED staff to remove the medications and presently there is no written process for the disposal of patient medications in the ED.
The Pharmacy Manager stated a more formalized process was needed.

The hospital also failed to identify the opportunity to improve communication and documentation. Per review of 'Emergency Physician Record' the ED physician documented on 12/30/09 Patient #2 had left AMA (Against Medical Advice) and had refused to sign the AMA form sometime after 18:00. At 19:00 after discussing Patient #2 with the patient's psychiatrist, the ED physician notes he/she was informed by the psychiatrist "....the patient could be a danger to himself...." and ".... had been abusive.......He/she recommended (the patient) be brought back to Emergency Room for involuntary commitment". Per interview at 8:25 AM on 2/23/10 the ED physician stated due to the concerns raised by Patient #2's psychiatrist, the police were contacted sometime after the patient signed out AMA. However, the ED physician confirmed he/she failed to document the police were contacted, was not aware which staff had made a call to the police department and there was no evidence in the patients's record the police were contacted.