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Based on interview and documentation review, the Hospital failed to ensure that grievances were addressed in a timely manner for 2 of 11 applicable patients (Patient #1 and Patient #11).

Findings included:

Review of the Hospital's Policy/Procedure titled Patient Complaint/Grievance Process effective May, 2010 indicated that complaints/grievances were entered into the electronic reporting system. The Director/Manager of the department implicated in the complaint/grievance was expected to contact the complainant by telephone within 48 hours of receiving the complaint to acknowledge the complaint. The Director/Manager was to provide their name and contact information, and ensure the complaint would be investigated. The Director/Manager was then expected to investigate/resolve the complaint/grievance. The Director/Manager was to contact the complainant via telephone and provide closure including an explanation of policies and discussions of alternative courses of actions. Final closure generally took place within 7 days of receipt of the complaint. If the investigation was not completed within 7 days then the Director/Manager was to contact the complainant and give an estimated time for completion. The Quality Management Department was responsible for coordinating a written response within 30 days of receipt of the complaint and included the investigation steps, the results of the grievance process, and the date of completion.

PATIENT #1:

Review of the Patient Complaint Log on 7/26/11 indicated that on 7/13/11 a grievance regarding medical care in the Emergency Department (ED) was entered into the electronic reporting system on behalf of Patient #1.

Review of the grievance documentation indicated the ED Quality Director was assigned to investigate the grievance. The first telephone contact with the complainant occurred on 7/18/11 (5 days after the grievance was entered) at which time a telephone message was left. A call was placed to Patient #1 and details of the grievance were discussed. Documentation indicated that on 7/20/11 the ED Physician involved in the grievance was interviewed and another call was placed to Patient #1 and a message left. There was no further documentation regarding the grievance.

The ED Quality Director was interviewed with the Chair of Emergency Services on 7/26/11 at 9:20 A.M. The ED Quality Director said he reviewed the medical record and interviewed the ED Physician and he did not find any problems with care. The ED Quality Director said the case was not closed because he and the complainant and Patient #1 have been playing telephone tag and had not yet connected .

The ED Quality Director did not contact the complainant and/or Patient #1 within 48 hours of receipt of the grievance. There was no evidence that the complainant or Patient #1 were informed of the date the investigation was expected to be completed which was still open on 7/26/11 (13 days after receipt of the grievance).

PATIENT #11:

Review of the Patient Complaint Log on 7/26/11 indicated that on 6/6/11 a grievance regarding medical care in the Emergency Department (ED) was entered into the electronic reporting system on behalf of Patient #11.

Review of the grievance and supporting documentation indicated responsibility for the grievance was assumed by the ED Quality Director.

Review of the grievance and supporting documentation indicated a telephone call was not placed to the complainant until 6/20/11 to discuss details of the grievance. There was no documentation of the steps taken to investigate the grievance and there was no documentation to indicate there had been further telephone communication. On 7/11/11 the case was closed and a written response was sent to the complainant.

The ED Quality Director did not contact the complainant within 48 hours of receipt of the grievance and did not document steps taken to investigate the grievance.

Based on documentation review the Hospital failed to ensure that the response letter sent to the complainant contained information regarding investigation of the grievance for 1 of 2 applicable patients (Patient #11).

Findings included:

Please refer to A-0122 for background information regarding Patient #11.

Review of the response letter dated 7/11/11, indicated it did not include the investigation steps or the results of the grievance process.

Based on documentation review the Hospital failed to ensure that Emergency Department (ED) physicians were 1) performing the initial examination in a timely manner for 2 of 10 applicable patients (Patient #1 and Patient #8) and 2) addressing the patient's pain for 2 of 10 applicable patients ( Patient #1 and Patient #5).

Findings included:

1) The Policy/Procedure titled Patient Assessment in Triage and Treatment Areas indicated that the physician was required to assess patients leveled as II or III within 30 minutes of arrival to the ED.

PATIENT #1:
Review of Emergency Department documentation dated 7/12/11 indicated that Patient #1 arrived to the ED at approximately 12:20 A.M. and was triaged (initial nursing assessment).

Review of the Emergency Care Report dated 7/12/11 indicated that Patient #1 was examined by the ED Physician but did not indicate the time of the initial examination.

Review of Physician Orders dated 7/12/11 indicated that initial orders were entered into the electronic medical record system at approximately 1:22 A.M.

The ED Physician was interviewed on 7/26/11 at 12:35 P.M. The ED Physician said he first saw Patient #1 shortly before the first orders were entered.

Patient #1 was seen approximately 1 hour after arrival to the ED.

PATIENT #8:
Review of the Triage Assessment dated 7/12/11 indicated that Patient #8 arrived at the ED at approximately 11:30 P.M. and was triaged at approximately 11:40 P.M. Patient #8, a pediatric patient, complained of upper abdominal pain for 9 days and lower abdominal pain for 1 day without nausea, vomiting or fever.

Review of the Clinical Notes dated 7/13/11 at 12:30 A.M. indicated that Patient #8 was brought to a treatment room walking and smiling.

Review of the Clinical Notes dated 7/13/11 at 2:20 A.M. indicated that Patient #8 continued to wait for physician evaluation. Documentation indicated that Patient #8 and Parents had left the ED without being seen.

Patient #8 was not seen until 1 hour and 50 minutes after arrival to the ED.

2) Please refer to A-0395.

PATIENT #1:
Review of the Triage Assessment dated 7/12/11 at 12:18 A.M. indicated that Patient #1 reported having bilateral flank pain rated as 8/10.

Review of the Emergency Care Report dated 7/12/11 indicated that Patient #1 reported flank pain.

Review of Physician Orders, the Medication Administration Record and Discharge Instructions dated 7/12/11 indicated that Patient #1's pain was not addressed. Patient #1 was discharged to home at approximately 7:25 A.M. (7 hours later) without discharge instructions or prescriptions for pain management.

PATIENT #5:
Review of the Triage Assessment dated 7/12/11 indicated that Patient #5 was experiencing shortness of breath and a low oxygen saturation level. Patient #5 had a medical history significant for chronic obstructive pulmonary disease. Patient #5 was triaged at approximately 1:58 A.M. and rated his/her chest pain as 8/10.

Review of Physician Orders, the Medication Administration Record and Discharge Instructions dated 7/12/11 indicated that Patient #5's pain was not addressed while Patient #5 was in the ED. Patient #1 was admitted to the Hospital at approximately 6:55 A.M.

Patient #5 was not reassessed for pain and was not given pain medication for 5 hours while in the ED.

Based on documentation review the Hospital failed to ensure that 1) pain was assessed/reassessed per policy for 2 of 10 applicable patients (Patient #1 and Patient #5) and 2) vital signs were taken according to policy for 2 of 10 applicable patients (Patient #1 and Patient #3).

Findings included:

Review of the Hospital's Policy/Procedure titled Patient Assessment in Triage and Patient Areas indicated that patients triaged (initial assessment) as a Level II or III (5 tier system with Levels I, II, III, IV, and V; level is assigned based on acuity of illness) were to have pain assessed and vitals signs (temperature, pulse, respiration, blood pressure, and oxygen saturation level) taken during triage and every 2 hours and with pain intervention.

1) PATIENT #1:
Review of the Triage Assessment dated 7/12/11, 12:18 A.M. indicated that Patient #1 reported having bilateral flank pain rated as 8/10.

Review of the Emergency Care Report dated 7/12/11 indicated that Patient #1 reported flank pain.

Review of Clinical Notes, Physician Orders, Medication Administration Record Vitals Signs Record and Discharge Instructions dated 7/12/11 indicated that Patient #1's pain was not addressed or reassessed. Patient #1 was discharged to home at approximately 7:25 A.M. (7 hours later) without discharge instructions or prescriptions for pain management.

PATIENT #5:
Review of the Triage Assessment dated 7/12/11 indicated that Patient #5 was experiencing shortness of breath and a low oxygen saturation level. Patient #5 had a medical history significant for chronic obstructive pulmonary disease. Patient #5 was triaged at approximately 1:58 A.M. and rated his/her chest pain as 8/10.

Review of Clinical Notes, Physician Orders, Medication Administration Record Vitals Signs Record and Discharge Instructions dated 7/12/11 indicated that Patient #5's pain was not addressed or reassessed while Patient #5 was in the ED. Patient #1 was admitted to the Hospital at approximately 6:55 A.M.

Patient #5 was not reassessed for pain and was not given pain medication for 5 hours while in the ED.

2) PATIENT #1:
Review of the Triage Assessment dated 7/12/11, indicated Patient #1 was triaged as a Level III priority.

Review of the Vital Signs Report dated 7/12/11 indicated that Patient #1's vital signs were taken and recorded at 12:20 A.M. during triage. Patient #1 had an elevated temperature of 100.4 degrees Fahrenheit (normal range is 97.8 to 98.8 degrees Fahrenheit) and an elevated pulse rate of 115 beats per minute (normal range is 60 to 100 beats per minute). Respirations, blood pressure and oxygen saturation level were within normal limits.

Review of the Vital Signs Report dated 7/12/11 indicated that vital signs were not taken and recorded until 6:00 A.M. at which time Patient #1's temperature and pulse rate remained elevated. A blood pressure was not recorded.

PATIENT #3:
Review of the Triage Assessment dated 7/11/11 indicated that Patient #3 was triaged as a Level III priority.

Review of the Vital Signs Report dated 7/11/11 indicated that Patient #3's vital signs were taken and recorded at 12:12 A.M. and were not repeated until 5:00 P.M. At 6:30 P.M. Patient #1 was admitted to the Hospital.