HospitalInspections.org

Based on document review and interview the facility failed to follow its policy and procedure related to prompt response for 1 (#1) of 12 sampled patients reviewed for grievances, resulting in the potential for unresolved and prolonged patient grievances. Findings include:

On 6/14/16 at 1625 during a telephone interview with the complainant the following concerns were identified. According to the complainant he was transported to the Emergency Room (ER) from another local health care facility under his own free will. The complainant explained that while he was in the ER crisis room all of his belongings were taken from him including his cell phone. He explained he had done nothing wrong and he did not know why he could not keep his cell phone. He said he was attacked by 5 people including Security staff while he was standing and holding onto his bed. He said he pissed his pants and was knocked unconscious by Security staff. The complainant said he needed Mental Health services. He stated "I was in a Crisis room. There was a camera in the room that recorded everything." The complainant explained that he was transferred from the facility to another local community facility by ambulance for treatment on the same day. The complainant explained he returned to the ER a few days later to complain. He stated "my eyes were still swollen and bloodshot red from being choked to unconsciousness from that attack." He stated, "there were bruises on my throat and chest from being jumped by security while being restrained, and I was 'blown off' by the ER staff when I requested to file a complaint."

On 6/15/16 at 1330 a review of the closed electronic medical record documented the following:
A review of the E Health Info Management sheet documented patient #1 was a 29 year old male who was admitted presented to the Emergency Department (ED) on 4/22/16 at 1025 am via ambulance. Diagnosis Information listed: Primary Visit Diagnosis: Suicidal ideation and Aggressive behavior. Discharge Disposition: Discharged on 4/22/16 at 2039 to (name of local behavioral health medical center).

On 6/15/16 at 1521 a review of the complaint/grievance log was conducted with the Director of Risk Management Staff (G). There were no complaints/grievances for patient #1.

On 6/16/16 at 1030 during an interview and review of patient #1's medical record the Patient Advocate Staff (P) explained she had received 2 calls regarding patient #1. Staff P stated the first call was a retrieved voice message from a local community healthcare facility from patient #1. She said the message did not indicate a reason for the call. She explained she did not write any dates or time that the voice message was received because the caller did not leave a reason for the call.

Staff P stated the second call was from their (ED) department on 4/27/16 that indicated the patient wanted to speak with someone regarding making a complaint. Staff P stated the patient never made it to her office. Staff P explained she made attempts to contact the patient with an alternate phone number that was listed on his face sheet that were unsuccessful.

On 6/16/16 at 1430 a telephone interview via speaker phone and record review was conducted with (ED) Registered Nurse (RN) Staff (R). The Director of Patient Safety and Quality Staff (A), the Director of Medical Surgical Services Staff (B), and Director of Risk Management Staff (G) were listening in for the interview. A Nursing Progress note authored by Staff R, dated 4/27/16 at 1703 documented the patient presented to the (ED) with a complaint of redness to his sclera both bilateral eyes. Patient upset and states that our security jumped him causing this eye injury. States he has been getting a headache every since." Staff R explained she recalled the patient was seen in the Triage room of the ED. She confirmed she documented on the patient's ED nursing notes that the "Patient complained of redness to sclera and said security jumped him. " When asked if she reported the patient's complaint of being jumped by security while in the (ED) she stated, "I may have said something to the charge nurse. He (#1) was upset accusing us of something I knew nothing about. He did ask me who he could make a complaint to regarding the incident. I was working Triage. I told him something. I don't recall exactly. I then directed him back to the waiting room. "

At that time, following the telephone interview the Director of Risk Management Staff G was asked to explain what the process was if a patient presented to the ED with a complaint. Staff G explained that it (complaint) should have been reported by whomever was notified at that time. However, there was no evidence provided that documented the patient's grievance had been reported.

On 6/15/16 at 1630 a review of the facility's " Complaints/Grievances-Resolution of Patient" policy, (dated 2/2016), documented:
Complaint Response/Investigation/Documentation
"1. The hospital employee hearing the complaint should:
a. Acknowledge the patient concerns by listening, being considerate, and taking all complaints seriously.
b. Obtain the facts from the individual making the complainant.
c. Determine who else has been involved or is knowledgeable about the complaint.
d. Consider the need for additional support; i.e., Department Manager, Patient Advocate, Social Work, Physician, Patient Accounting, Pastoral Care, etc.
e. Ask the person to identify the resolution they are seeking.
f. Offer an apology and make amends by determining the response to put closure to the situation (i.e., follow-up letter, phone call, or meeting). If you are unable to put closure to the situation, the complainant then becomes a grievance...
2. If you as an employee, are involved in, observe, or discover a patient complaint that cannot be resolved to the patient's satisfaction, you are responsible for notifying your immediate supervisor/manager...".