HospitalInspections.org

Based on document review and interview the facility failed to follow its own policy and procedure and ensure there was a resolution to patient complaints/grievances in 4 (Patients #21, #23, #24, and #25) of 5 patient complaints/grievances reviewed. The facility also failed to notify the complainant the facility received the complaint and an internal investigation would be conducted according to facility policy.


This deficient practice had the likelihood to affect all patients.


Findings:

A review of the Complaint and Grievance Log for the Emergency Department was conducted with Staff #5 on 4/28/2021 after 9:00 AM. The document contained the following information: Patient name, Sex, Date of birth, Case Summary, and Actions. Staff #5 confirmed all information was entered on this document by her.


Patient #21

Patient #21 was a 47-year-old female seen in the Emergency Department on 11/11/2020 at 10:14 AM.

Staff #5 confirmed the complaint was received on 1/6/2021.


" ...Case-Summary

Service Failure-complaint

Patient states that she came to ED via EMS 11/11/2020. States that she could not move her hand and had a headache and trouble seeing. Labs drawn and patient were told they were normal. Dr. Corwin reported to be mean and not compassionate, telling the patient she was just hyperventilating and that he he (sic) did not know why she was there because he could not do anything for her. Patients husband then took her to Baylor Waxahachie where they reportedly diagnosed with a stroke.

Patient presented to ED on 11/11 with c/o of anxiety via EMS. Complains of pain in pelvis not currently in pat at presentation. VSS. History of chronic pelvic pain greater than 1 year and "something wrong." She agrees with nausea and pelvic pain. Became overwhelmed with uneasy feeling while driving to OB physician in Waxahachie. EKG and lab work all normal. Ativan provided IVP. Discharged home with prescription for Bentyl and instructions to follow-up with provider in 2-3 days.

Actions:

Attempted to reach patient for information. No response/no call back.
No concerns with care identified ..."

An interview was conducted on 4/28/2021 after 9:00 AM with Staff #5.

Staff #5 was asked when was the complaint filed with the facility. Staff #5 replied, "The complaint was made 1/6/2021 by the significant other and the complainant left no name. It was brought to my attention after the Quality Department saw a negative review on Facebook."

Staff #5 was asked if the grievance had been investigated and closed. Staff #5 stated, "It has not been closed. I have tried to contact the patient and cannot get a return call." Staff #5 was asked if there was documentation of dates and times attempts were made to contact the patient. Staff #5 stated, "No I don't have any of that. I did speak to Staff #9 about the patient complaint. The medical record was reviewed by Staff #9 and it was determined that appropriate care was given." Staff #5 confirmed all complaints that are specific to providers are reviewed by the Quality Department. Staff #5 could not confirm nor deny if the complaint was reviewed by the Quality Department.

Staff #5 confirmed the complaint was about the care Patient #21 received from Staff #9. Staff #5 also confirmed Staff #9 completed the internal chart review and deemed all care was appropriate for Patient #21.

Staff #5 was asked if a letter had been sent to the patient regarding the internal investigation. Staff #5 said, "The Quality Department does all the follow up letters."

An interview was conducted on 4/28/2021 after 12:30 PM with Staff #11.

Staff #11 was asked if an investigation into the complaint by Patient #21 was complete. Staff #11 stated, "The complaint was given to Staff #5 to investigate because it occurred in the Emergency Department. The Quality Department did not complete an internal investigation."




Patient #24

Patient #24 was a 27-year-old female admitted to the Emergency Department on 3/22/2021.

Staff #5 confirmed the complaint was received on 3/22/2021.

" ...Case Summary

Service Failure-complaint

Father of adult patient called (Emergency Department) ED multiple times, after leaving message with Risk Management the call was forwarded to House Supervisor phone. Per father his daughter was seen in the ED yesterday 3/22/21 morning with a complaint of back pain and "worst headache of life" States she had nuchal rigidity, and fever. Reports she has some x-rays and CT scans and was discharged with "Bacterial Meningitis." He states this is not the first time this has happened, and that he is concerned because everyone around her was exposed to meningitis. He states that she is also pregnant. Would like someone to investigate this issue and call him back.

Patient 6 weeks pregnant, no OB care. She stated that day prior to arrival felt needles shoot across and up and down her whole back. She has HA upon presentation and "feeling of someone pulling on her spine". States she took Tylenol and Gabapentin without relief. BP on admit 136/86 on arrival with pain 6/10 on pain scale. Temp 99.6 at 0513. Denied dysuria.

Actions:

Patient's father as well who said that Patient #24 (***) was admitted to Baylor Waxahachie after being d/c home ..."


An interview was conducted on 4/28/2021 after 9:00 AM with Staff #5.

Staff #5 was asked if the complaint had been investigated and finalized. Staff #5 said, "I have completed the initial chart review and I have tried to call the patient. I did not speak to the patient's father because the patient is of legal age. I have not talked to the physician or the staff that was involved in the complaint and the investigation is still open." Staff #5 was asked when she attempted to contact the patient. Staff #5 stated, "I did not write any dates or times down when I tried to call."

Staff #11 also confirmed no initial letter had been mailed to the complainant or patient.




Patient #23


Patient #23 is an 85-year-old male who presented to the ER on 1/17/2021.

Staff #5 confirmed complaint was received on 2/25/2021.

" ...Case Summary

Service Failure

" ...Information received from Staff #19: I just received a call from Patient #23 (**********). He was very unhappy with the treatment he received in the ER. He says that he came in three weeks ago on a Sunday with headaches and chest pain. He was very ill. He was put in Room 13 and no one came to see him. He says the dr that saw him took his socks off and threw them across the room and told him to go home and rest. He says a gray headed nurse told him that all he wanted was pain pills and that he needed to go home. Patient #23 says he has never taken pills and only takes Tylenol.

He says that his regular physician told him to come to the ER for treatment of which he received none.

Actions:

Quality Coordinator spoke with Patient #23 on 2/25/2021. His primary complaint is that the physicians/staff are rude and always send him home without addressing his issues. Spoke with ED Director who has reviewed his chart. Patient noted to have become impatient and left AMA after about 30 minutes.

Patient arrived at 0920 chief complaint was a urinary problem. Labs ordered including UDS (urine drug screen) and UA (urinalysis) were completed at 0927 pt was demanding medication for anxiety and pain. When MD denied request pt left AMA at 0933. No concerns with care identified..."


An interview was conducted on 4/28/2021 after 9:00 AM with Staff #5.

Staff #5 said, "A medical record review was completed and Quality does all reviews related to MD complaints. Staff #5 also said," There has been no resolution on this one."

An interview was conducted with Staff #11 on 4/28/2021 after 9:00 AM.

Staff #11 was asked if the facility mailed a letter to the patient informing him of the outcome of the investigation. Staff #11 stated, "I do not have anything showing any communication was made with the patient."

Staff #5 confirmed there was no documentation of dates and/or times the patient was contacted.



Patient #25

Patient #25 was a 63-year-old male presenting to the Emergency Room on 4/6/2021 at 11:35 PM

Staff #5 confirmed the complaint was received on 4/6/2021 by a hospital employee.


" ...Case Summary

Service Failure

Received call from Staff #20, **** stating that the security guard is being rude and hostile towards the pt. She said the security guard is yelling at the pt and the pt is sitting there.

Assessed the situation and the police officer ******is sitting across from the pt. The pt was quiet sitting in a chair with handcuffs on with his head bowed. Pt did not show any hostility towards any staff member or the Security guard when present. Pt did sit there quietly nodding off to sleep.



Actions:

Security guard was attempting to alert police officer that was sitting next to patient of patients status and risk for falling due to drowsiness. No trends of complaints previously on employee. Security guard supervisor will meet with team member to discuss perception of experience ..."

Staff #11 confirmed the Quality Department did not have any information on the complaint and there is no documentation regarding the investigation. There has been no communication either verbally or in writing with the complainant.


An interview was conducted on 4/28/2021 after 9:00 AM with Staff #11.

Staff #11 was asked how the complainant was informed that a complaint was received by the facility. Staff #11 stated, "We send a letter within 7 days to the patient or complainant acknowledging that we received the complaint and we will be completing an internal investigation. Then, we send another letter in 30 days or sooner when the investigation is complete. Sometimes the investigation takes longer and we will notify them in writing also."

Staff #11 was asked if the complaints/grievances for Patient's #21, #23, #24, and #25 had been completed and closed. Staff #11 stated, "I do not have any information on the complaints/grievances. I also do not have any documentation other than what was provided to you. Staff #5 did not document any times or dates of calls made to any patients. I also do not have any documentation of a letter being sent to Patients #21, #23, #24, or #25."


A review of the policy titled, "Complaint and Grievance Process (service Failure)" Policy #12.2 with an effective date of 06/08 and a revised date of 10/20 was as follows:

Page 4 of 11:

" ...The Hospital Quality Improvement Committee or Physician Practice Management ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital/Agency/Practice receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit. The written notice shall contain the following:

Name of the Hospital/Physician Practice contact person.
Steps taken on behalf of the patient to investigate the grievance.
Results of the grievance process.
Date of completion

If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that a follow-up written response will be provided within a specified time period but not to exceed 30 days until the grievance is resolved. If the grievance remains unresolved after 30 days, additional written follow-up would be indicated within a specified time period but not to exceed an additional 30 days ..."

After multiple requests for documentation of the internal investigations of complaints/grievances for Patients #21, #23, #24, and #25 no further documentation was alleged or provided for review.

Staff #5 and Staff #11 confirmed the above findings.

Based on interview and record review, the facility failed to ensure the Emergency department (ED) was organized in a manner to ensure thorough assessments and screening in 1 of 28 sampled patients who presented to the emergency room (Patient #14).

The facility failed to ensure a patient presenting with complaints of rectal bleeding received an assessment of the rectal area or testing to determine the severity of the bleeding.

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with gastro-intestinal bleeding.


Findings include:


Review of the ED triage assessment on Patient #14 revealed she was a 21- year- old female who presented to the ED on 11/24/2020 at 6:47 p.m. Patient #14 presented with complaints of blood in her stool. Patient #14 was assessed as having an emergency severity level of 4 (meaning her condition was semi-urgent).


Review of the triage notes dated 11/24/2020 at 7:58 p.m., revealed the following;

"Patient states she has had blood in her stool for past 3 months, seen by PCP and confirmed with occult blood. PCP states she needed a referral, patient states she has an appointment but just doesn't feel good."


Review of vital signs at 7:19 p.m., revealed there was a blood pressure of 120/73, pulse of 71, respirations of 18, temperature of 97.4 and an oxygen saturation level of 100 percent.


Review of the nursing triage notes dated 11/24/2020 revealed there was no documentation of an assessment of the rectal area.


Review of the physician notes dated 11/24/2021 and timed 8:16 p.m. revealed Patient #14 presented to "the emergency department with rectal bleeding, a small amount, on toilet paper, in toilet bowl."


Review of the physician's assessment dated 11/24/2021 revealed no documentation of an assessment of the rectal area or orders for any other test to determine if the patient's blood loss was severe.


Review of the ED record revealed Patient #14 was discharged at 8: 27 p.m.


Review of discharge instructions named "Rectal Bleeding" which was given to Patient #14 revealed the following:

"Rectal bleeding is when blood passes out of the anus. People with rectal bleeding may notice bright red blood in their underwear or in the toilet after having a bowel movement. They may also have dark red or black stools.

Rectal bleeding is usually a sign that something is wrong ..."


During an interview on 04/28/2021 after 12:15 p.m., Staff #17 (quality registered nurse) confirmed there was no nursing or physician assessment of Patient #14's rectal area. There were no other test performed on Patient #14 to determine if she was having blood loss.

During an interview on 04/28/2021 after 4:05 p.m., Staff #9 who was the physician who treated Patient #14 on 11/24/2020 revealed that for a patient coming in with rectal bleeding, their normal process would be to assess the rectal area to see if there were hemorrhoids causing the bleeding and get labs.

During the exit on 04/28/2021 after 6:01 p.m., Staff #6 (Chief nursing officer) stated something would be done to address the assessment issues identified in the ED.



Review of the facility's policy named "Triage Assessment of Patients (Tier 5) with a review date of December 2017 revealed the following:

"...the assessment should be appropriate to the presenting signs and symptoms and may include complete vital signs, O2 saturation for dyspnea/chest pain and trauma, body systems assessment as indicated by ED Standards of Care Manual, history of immunizations, current medications, allergies, height, weight, and medical and surgical past history.."


Review of the facility's policy named "Scope of Service" with a review date of June 2018 revealed that all patients presented to the hospital should receive the following:

A medical screening exam by an Emergency Department physician that includes providing all necessary testing and on call services within the "capability" of the hospital to reach a diagnosis. "Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner.."