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Based on interview and record review it was determined the facility failed to provide a written notice regarding the resolution of a grievance for one (1) of twenty-one (21) sampled patients (Patient #1). Patient #1's guardian and physician complained to hospital administration that Patient #1 was not assessed/screened in the facility's Emergency Department (ED). The Community Chief Regulatory Affairs Officer (CCRAO) was aware of the complaint and told the patient's guardian that she would follow up with him but failed to notify the guardian of the steps take on behalf of the patient to investigate the grievance, the results of the grievance process, or the date the investigation was completed.

The findings include:

Review of the facility's "Patient Grievance Policy," dated 01/30/09, revealed, "It is the policy of the facility to establish a process for prompt resolution of patient grievances and to notify each patient [or patients guardian] whom to contact to file a grievance. The facility must clearly explain the procedure for the submission of a patient's written or verbal grievance to the hospital or facility. The procedure for a patient or the patient's representative to submit verbal or written reports must be clearly explained in a manner that the patient or patient's representative should be able to understand." Continued review of the policy revealed a verbal complaint that could not be resolved at the time the complaint was made by staff present, the complaint was postponed for later resolution, referred to other staff for later resolution, required investigation, and/or required further actions for resolution, and then the complaint was a grievance for the purpose of these requirements. The policy stated grievances should be routed to the Community Chief Regulatory Affairs Officer.

Interview with Patient #1's guardian, who is a paramedic, on 02/04/15 at 2:30 PM, revealed he took Patient #1 to the facility's ED on 12/20/14 for treatment for difficulty breathing. He stated that he spoke with Registration Clerk #1, who told him the ED was "busy" and it would be "two hours" before Patient #1 could be seen. The guardian also stated that Registration Clerk #1 told him the outpatient clinic, located in a different community, was open and seeing patients. He stated RN #1 walked into the triage area and said "hello" to him, but never asked what he was doing in the ED or if Patient #1 had been triaged, even though Patient #1 was wheezing and having difficulty breathing. The guardian stated he left the facility with Patient #1 and drove 45 minutes to the outpatient clinic (Facility #2). Patient #1 was evaluated and treated by Physician #1, then transferred back to the facility and admitted on 12/20/14, with a diagnosis of Croup.

An attempt to obtain Patient #1's ED medical record from the facility for the visit on 12/20/14 was made; however, the facility did not have a record of Patient #1 being in the ED. Interview with RN #1 on 02/05/15 at 11:50 AM and with Registration Clerk #1 on 02/05/15 at 1:50 PM revealed Patient #1 did not have a medical record for the ED visit because the facility did not assess the patient.

Interview with Registration Clerk #1 on 02/05/15 at 1:50 PM revealed she was working in the ED on 12/20/14. She stated that Patient #1's guardian brought the patient to the ED. She stated the guardian asked if the ED was busy and she stated "yes." Registration Clerk #1 stated she informed Patient #1's guardian that the ED was full, people were waiting in the lobby, and it would be around two (2) hours before Patient #1 would be seen. Continued interview revealed Registration Clerk #1 informed the guardian that the outpatient clinic (Facility #2) in a nearby community was open and seeing patients.

Interview with Registered Nurse (RN) #1 on 02/05/15 at 11:50 AM revealed she was working as the triage nurse in the ED on 12/20/14. She stated she was assisting a patient in the ambulance bay and walked into the triage area and spoke to Guardian #1, but did not triage Patient #1 because the guardian was walking away from the desk.

Interview with Physician #1 on 02/05/15 at 12:00 PM revealed he received a text message from Patient #1's guardian on 12/20/14 asking the physician if he would see Patient #1 at the outpatient clinic (Facility #2). He stated he told Patient #1's guardian to bring the patient to the clinic. Continued interview revealed that when Patient #1 presented to the clinic, the physician was with a patient in another room, but could "hear [Patient #1] breathing from the lobby" and that anyone who came in contact with Patient #1 could have heard that the patient was having difficulty breathing. The physician stated Patient #1 required treatment for approximately one hour before Patient #1 was "somewhat" stabilized. Physician #1 stated he contacted ambulance services to transport Patient #1 back to the facility for admission and treatment; however, an ambulance was not readily available. Due to the patient's condition, the physician provided a portable oxygen tank for the patient to utilize while the guardians drove the patient back to the hospital. Physician #1 stated he contacted Physician #2, a Pediatrician, who agreed to meet the patient at the facility. Physician #1 stated he contacted the CCRAO at the facility and complained that the facility did not screen Patient #1 in the ED.

Review of Patient #1's medical record from the outpatient clinic (Facility #2) revealed when the patient presented to the clinic on 12/20/14, Patient #1's oxygen saturation was 84% (normal is 95-100%) and his/her respiratory rate was 40 (normal for a 12-month-old is 18-30). The medical record further revealed that the patient did not have a fever, but was retracting (the skin between the ribs pulls in during breathing), had stridor respirations, and "you could hear [the patient] breathing in the lobby." The physician at the outpatient clinic diagnosed Patient #1 with Croup and admitted Patient #1 directly into the hospital.

Review of Patient #1's medical record from the facility revealed Patient #1 was admitted on 12/20/14 with diagnoses of Croup and Respiratory Distress. Upon admission, the patient's temperature was 99.6, the patient was in mild respiratory distress, and was "ill in appearance."

Interview with Physician #2 on 02/05/15 at 1:10 PM revealed she met Patient #1 at the facility on 12/20/14. She stated Patient #1 had audible "stridor" (Stridor is a high-pitched breath sound, which is caused by a narrowed or obstructed airway. Inspiratory stridor often occurs in children with croup). She stated she was aware that Patient #1's guardian was upset because Patient #1 had not been seen in the ED and had to be taken 45 minutes away to be treated in an outpatient clinic. She stated she also complained to the administrator of the facility because Patient #1's guardian requested her phone number, but the facility failed to contact her or give the guardian information on how to contact the pediatrician. Physician #2 also stated the ED physician could have contacted her and she would have admitted the patient.

Interview with RN #2 on 02/05/15 at 12:45 PM revealed she was working as the House Supervisor on 12/20/14. She stated the CCRAO called and asked her to speak with Patient #1's guardian. RN #2 stated she spoke with the guardian and he was upset because the ED failed to see Patient #1 and he had to take the patient 45 minutes away to an outpatient clinic and then back to the facility for admission. RN #3 stated she assured Patient #1's guardian that she would inform administration of the concerns and make sure "things like this" did not happen again.

Interview with Patient #1's guardian, who is a paramedic, on 02/04/15 at 2:30 PM, revealed the hospital Community Chief Regulatory Affairs Officer contacted him regarding the facility's failure to assess/screen Patient #1 in the ED on 12/20/14. The guardian stated she apologized and stated she would look into the incident and follow up with him; however, he had no further contact from the facility.

Interview with the Community Chief Regulatory Affairs Officer on 02/09/15 at 4:30 PM revealed she received a complaint from Physician #1 and Physician #2 and was informed of Patient #1's guardian's complaints regarding the lack of care Patient #1 received in the Emergency Department. She stated she phoned the guardian and spoke with him and told him that she would follow up, but she meant that she would follow up with staff, not the guardian. She stated she never provided a written response to the guardian because she thought the issue was resolved.