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Based on interview and document review, it was determined that the hospital (a) did not fully investigate and resolve all grievances received, (b) did not ensure that written responses to each patient's grievance contained all of the required elements. This finding was identified in one (1) of one (1) grievance files reviewed.

Findings include:
Review of grievance file # 1, reviewed on 6/10/16, showed that the facility received an e-mail from the complainant regarding services rendered in the Emergency Department in 2015 and 1/1/2016.
It was noted the only investigation listed in the grievance file was a letter titled "to whom it may concern" and had signatures of the physician and the nursing staff. The letter was dated 1/1/16. In this letter, there was a description of the patient's bad behavior and treatment towards the hospital staff on 1/1/2016.
There was no documentation in the grievance file of the investigation process taken by the facility. In addition, the response to the complainant did not include all the elements described above, as stated in the regulation.
This grievance issue was discussed with Staff B, Manager of Patient Experience on 6/10/16.

Based on observation, interview, medical record review, and document review, it was determined (a) in three (3) of nine (9) medical records reviewed that the facility failed to ensure each patient presenting to the Emergency Department (ED) receives evaluation and treatment, in accordance with its written policy and procedure, and (b) Emergency Department polices were not updated. (Patient #3, #4, #19)

Findings include:

a) During a tour of the facility's Emergency Department (ED) on 6/13/16 at approximately 11:30 AM, patient #4 was seated in the waiting room and was interviewed by the surveyor. This patient stated that she had been waiting for a long time and she had not been assessed by any clinical staff. It was noted that the patient #4 was listed on the ED White Board as waiting 1:15 (1 hour and 15 minutes) to be triaged.
Observation of the ED White Board noted Patient #19 had been waiting 40 minutes for triage and it was also noted that patient #19 was placed in triage Category 2.
During interview with Staff E, Registered Nurse, at approximately 11:39 AM, Staff E stated that when a patient walks into the ED, he/she discusses the chief complaint with her (greeter nurse) before the patient is registered. This staff stated that based on the patient' s chief complaint, she decides if the patient can wait and she assigns the triage category.

Review of the medical record for Patient #4 noted: The 74 year old patient, was triaged 6/13/2016 at 11:14 AM. The chief complaint was hip pain and the patient was triaged at ESI (Emergency Severity Index) triage acuity Level: 3; there were no vital signs noted.
ED Triage Extended notes entered on 6/13/2016 at 12:24 PM indicated that the chief complaint was hip pain chronic; ESI triage acuity level: 3. Vital signs: temperature 98.5, heart rate 87 bpm, respirations 20, oxygen saturation 100%, blood pressure 153/93. The patient was triaged to fast track.
Medical Screening examination was initiated on 6/13/2016 at 13:03 (1:03 PM). The medical history included: osteoporosis, DM (diabetes), CAD (cardiovascular disease), HTN (hypertension), and with new onset left-sided throbbing aching hip pain x I week. The patient also reported that she came to the ED because she was having palpitations and flutters to her heart that lasted for about five minutes forcing her to take nitroglycerin for twice in the past two days. After medical evaluation, the decision was made to admit the patient to CSCU (cardiology / surgical services unit). It was documented that on 6/13/2016 15:01 (3:01 PM) the medical resident came to evaluate the patient but the patient eloped.

It was noted that the initial triage did not include vital signs and the patient waited over an hour from time presented to complete triage. The nursing triage assessment did not document pain assessment and the patient' s medical history.

Review of the medical record for Patient #19 noted: This 77 year old patient was triaged on 6/13/2016 at 11:48 AM. The chief complaint was fatigue and weakness, patient was assigned ESI (Emergency Severity Index) triage acuity Level 2 (Complaints require rapid medical attention but are not likely to cause death, loss of function or extreme discomfort). There were no vital signs noted.
The Triage Extended note on 6/13/2106 at 12:25 PM indicated that the chief complaint: fatigue and weakness; generalized weakness unable to stand by herself as per daughter and lethargic and heart beating fast. Vital signs: Temperature 99, heart rate 83 bpm, respirations 20, blood pressure 120/67. The patient had nursing reassessment on 6/13/2016 at 16:16 (4:16 PM).
Medical Screening Exam was initiated on 6/14/2016 at 05:15 (5:15 AM), approximately 18 hours after triage Level 2. The provider noted, 77 year old with history of CAD (cardiovascular disease) with stents, diabetic neuropathy, presented to ED with generalized weakness x 3 days, unable to ambulate without assistance x 3 days. She also has decreased alertness and decreased appetite. The patient was admitted, the decision to admit was dated 6/13/2016 at 17:46 (5:46 PM) and the patent departed from the unit on 6/13/2016 at 21:57 (9:57 PM). The initial Medical Screening evaluation was dated 6/14/2016 at 5:15 AM, after the patient departed from the ED for inpatient admission.
Staff N, Director of ED Nursing, was interviewed on 6/14/2016 at 2:00 PM. The staff stated upon arrival in the ED, the patient sees the screening nurse who places the patient into the triage category. She stated that determination on the triage category is based on the chief complaint. This staff stated that the main triage nurse does the actual triage and takes the patient's vital signs.
Emergency Department Policy titled "Triage in the Emergency Department, "revised 7/24/14 states: "Patients entering the Emergency Department will be greeted by Nurse First; (Pre Triage), he/she will perform Tier One Triage (First Look Assessment) and determine an initial acuity utilizing the Emergency Severity Index." The policy also states that 4 decision points are listed to sort patients into one of the five triage levels and this includes the patient's vital signs.
Patient #4 & #19 were assessed and the initial acuity was determined utilizing the Emergency Severity Index, but the vital signs were not taken, as specified by the policy.

Patient #19 was triaged and categorized as ESI Level 2 and the medical screen was initiated approximately 18 hours after triage.
The Emergency Department policy titled "Triage in the Emergency Department," revised 7//24/14, states that patient placed in triage level 2 requires rapid medical attention. This patient waited approximately 18 hours after triage for the initial medical screening examination.
A similar finding was noted during medical record review for Patient # 3: The patient, 31 year old female, was seen in the ED on 4/24/2015 with chief complaint of vomiting, diarrhea x one day. Vital signs: temperature 98 F, heart rate 115, respirations 18, oxygen saturation 98% and blood pressure 129/78. This patient was assigned to triage level 2. The patient was triaged on 4/24/2015 at 9:28 AM and had a medical screening exam initiated on 4/24/2015 at 10:28 AM. This patient waited one hour after triage for the initial medical screening examination.


b) Review of the facility's "Emergency Labor and Delivery Triage" policy noted this was last revised on 1/07. Discharging patients from ED, policy # 660.1, was last revised on 1/11; these policies were not updated. This issue was brought to the attention of Staff L, RN Director of Maternal & Child Health.