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Based on review of grievance records, procedures, and interviews with staff, it was determined that the hospital did not conform to facility procedures due to lack of complete documentation of investigation of grievance issues and thus did not fully resolve patient grievances.

Findings include:

Review of the hospital policy titled " Patient Complaint Grievance program " on 1/30/14 finds that the complaint issues shall be resolved by staff, reported to the departmental managers who will attempt to resolve the grievance, and also reported to Patient Relations departmental staff.

The facility did not conform to its own procedures because 9 of 13 grievance files reviewed on 1/30/14 did not include documentation of complete investigations as follows:

Grievance file #1
The file noted the patient complained on 7/10/13 that she waited 1 hour in the waiting room for chest pain. The security officer blocked her from entering to speak with the nurse and that he harassed her telling her he would throw her out and she would not be seen. The patient threw her cell phone at the security officer. An investigation was conducted by the hospital which included witness interviews with Security and nursing staff. It was concluded that while the patient was angry, the officer did not maintain professionalism and was counseled.
There was no investigation to determine if the patient ' s wait was excessive. Review of the patient ' s emergency record on 1/31/14 found that the patient was triaged at 9:37 PM on 7/3/14 with complaint of chest pain and classified as emergency severity index, ESI 2. The patient ' s EKG was timed at 9:14 PM and noted sinus tachycardia.
Review of the investigation file found that grievance information was not consistent with information that was documented in the patient's medical record reviewed. The grievance investigation did not address the length of the wait for triage. The investigation not address a finding for why the patient was ordered to have a security watch at 12:02 PM on 7/3/13 for purposes of psychiatric evaluation and that this obsevration was discontinued at 5:42 PM on 7/3/13. (which was more than nine hours prior to documented triage). At interview with the staff #2 on 1/31/14, no explanation could be provided for why the patient was placed on security watch 9 hours prior to medical triage.


Grievance file #2
Review of the grievance file on 1/29/14 found this patient ' s mother complained on 9/24/13 that her daughter was improperly cared for while in the psychiatric adolescent area in ED-3. It was alleged her daughter attempted to hurt herself twice and that staff were not watching her child. Medical and nursing staff reported the child was on continuous supervision but another hospital reviewer indicated an extra nursing attendant had started that week. The email responses did not address all the grievance concerns including the allegation that the patient was not bathed. The investigation did not evaluate or conclude if staff supervision was adequate.

Grievance file #3
A written complaint submitted by the partner of a patient who reported witnessing security staff punch another patient in the emergency room on 7/31/13. When reporting this situation, the complainant and her partner (the patient) were allegedly told to leave by the Nursing Director. The investigation file included a review by the Nursing Director of ED who reported the patient and complainant became threatening when the partner was asked to leave the emergency room with the other visitors until a situation involving a violent intoxicated patient was under control. A security department review was not submitted with the grievance file for review by the surveyor. The investigation did not evaluate if actions taken were appropriate with the violent patient, including a review of the patient's record.


Grievance file #6
Patient ' s family filed a complaint on 10/17/13 that the patient had been discharged from the emergency room wandering the street in a hospital gown. Additional complaints were filed about cleanliness in the emergency room during a return visit and that the ED Nursing Director Staff #2 was rude and pointed in the family ' s face. In the complaint file, the hospital reviewer described follow up which found there was a verbal interaction between the family member and the ED Nursing Director that required Security involvement. The nurse manager acknowledged the agency nurse who discharged the patient in a gown was dismissed. However, the grievance file contained documentation by the hospital's reviewer, who noted that it could not be substantiated that the patient had left in hospital gown. The reviewer did not address this inconsistency in findings obtained. The case was closed on 10/23/13 and there was no evidence the facility followed up on these contradictory findings noted about the manner in which the patient was dressed at discharge.


Grievance file #7
On 1/16/14 the patient complained a security officer placed his hands on him for no reason. The patient complained he sustained scratches on the neck during the event and provided a physical description of the officer (but no name was provided). Security Department review noted on 1/20/14 that an investigation could not be conducted due to insufficient detail provided and that two voice mails were left for the patient with no response. The review included no chart review, no review of the schedule roster for the date matching the patient encounter, and no attempt to contact the complainant by mail correspondence.

Grievance file #8
On 4/30/13, the patient complained of the experience having surgery in the Ambulatory Surgery center. He complained he was not assisted with a wheelchair by security, the nurse failed to provide pain medication, there was a excess delay on transport, the dietary meals was of poor quality, and about temperature control in that the room was too cold. The hospital review indicated the patient ' s report about the failure to assist with a wheelchair was inaccurate. While the dietary issue was addressed, the grievance file lacked follow up resolution of the transport issue. The record lacked follow up investigation of the pain medication issue.

Grievance file #10
The patient complained on 12/4/13 she waited in the ER for 11 hours with no asthma treatment in the emergency room. The grievance file contained actions taken to visit the patient who was anxious and who was receiving medication via mask and able to take medication. She was upset about waiting too long for a bed. On 12/5/13 the hospital staff visited the patient, who had been admitted and she was satisfied. Although the facility determined the patient was satisified, there was no notation by facility staff to address the potential delay in treatment.


Grievance file #12
On 1/16/14, a patient ' s sister complained the emergency room was too crowded with lack of privacy. She reported the stretchers are too close together and she requested transfer. The patient was requesting a breast pump. Staff noted situation is resolved but did not describe if the complaint was validated or describe actions taken other than provision of breast pump. The hospital representative followed up and acknowledged the patient ' s receipt of the pump and redirected medical concerns to her physician. The investigation lacked review of concerns about overcrowding and privacy.

Grievance file #13
On 10/2/14, the patient ' s daughter in law complained the patient was not provided with diabetic medication for more than eight hours in the emergency room. The complaint was referred to ED administrative staff including the Medical Director of Emergency, the evening supervisor, and to the Nursing Director of Emergency.
The administrator spoke with the husband and another relative, and reviewed the record for time and treatment. The patient and the family left the emergency department (ED) without signing out against medical advice (AMA). Outcome in file notes patient/family " satisfied ", that a response was given to the patient, and the complaint was closed out on 10/7/13. However, the investigative file did not identify the results of record review to ascertain if the treatment delay was verified.
At interview with Staff #1, it was reported that overall issues with grievance resolution are ongoing for improvement and will be managed by Patient Relations staff .

Based on review of grievance records, procedures, and interviews with staff, it was determined that the hospital did not fully respond to complainants in writing with feedback that incorporated the steps taken to investigate each complaint issue and complete results of the hospital's grievance investigations.

Findings include:

Review of the hospital policy titled " Patient Complaint Grievance program " on 1/30/14 notes that any complaint not resolved in 24 hours will become a grievance and if not resolved within 6 calendar days an interim letter will be prepared indicating that the facility is still attempting to resolve the grievance. A final letter will be sent within 30 days from the date the grievance was received. It is required this document contain: " the name of the hospital employee for contact, the steps taken to investigate the grievance, the results of the investigation, the date the investigation was completed, and notice of the right to contact the Department of Health and/or the Joint Commission by telephone or writing "

The facility did not conform to its own procedures since review of 10 of 13 patient grievance files on 1/29/14 and 1/30/14 lacked documentation of the provision of any response. Three of 13 grievance files reviewed included provision of a written response, but the correspondence lacked sufficient detail of the specific findings obtained or notification of the option to contact external regulatory or accreditation agencies in the event the complainant is dissatisfied with the response.

The following grievance files did not conform to its grievance procedure that requires provision of complete written responses as follows:

Grievance file #1
The file noted the patient complained on 7/10/13 that she waited 1 hour in the waiting room for chest pain.
The response letter provided to the complainant was delayed (dated 8/6/13) and did not discuss the specific findings. The letter contained vague language about " incorporating actions for meaningful improvement " . There was no information about the option of how to contact regulatory agencies for independent reviews, other than reference to a patient Bill of Rights enclosure. The investigation and written response letter did not address all of the allegations. For example, the response did not include an explanation to determine if the patient ' s wait was excessive.

Grievance file #2
Review of the grievance file on 1/29/14 found this patient ' s mother complained on 9/24/13 that her daughter was improperly cared for while in the psychiatric adolescent area in ED-3. The child had attempted to choke herself with her hospital gown in the psychiatric area of the emergency room where adolescents are held. The case was closed on 10/1/14 but despite attachments referenced for the investigation, no letter of response to the complainant was attached with the results of the grievance review.

Grievance file #3
A written complaint submitted by the partner of a patient who reported witnessing security staff punch another patient in the emergency room on 7/31/13. When reporting this situation, the complainant and her partner (the patient) were allegedly told to leave by the Nursing Director . The final response letter provided to the complainant dated 8/8/13 indicated an investigation was performed and that no further action is to be taken, The response letter did not disclose the specific findings nor the results of the security review.

Grievance file #4
On 9/27/13 the patient complained to medical staff that she observed her intravenous fluid bag had the name of another patient. The event was substantiated. While staff did speak with the patient, no formal letter of response was provided with the investigative results in the grievance record.

Grievance file #5
On 7/25/13 a complaint was filed by the family of a patient where it was alleged that on 7/24/13, the security officer hit the patient around the face . Review of the response letter provided to the complainant dated 7/30/13 noted " an investigation was undertaken into this matter with involved staff. Upon review of this case, it did not indicate any further action is to be taken. " No explanation of findings was documented.
Grievance file #6
Patient ' s family filed a complaint on 10/17/13 that the patient had been discharged from the emergency room wandering the street in a hospital gown. The case was closed on 10/23/13 and there was no written letter of response attached to the grievance file with evidence of a written response provided to the complainant.

Grievance file #7
On 1/16/14 the patient complained a security officer placed his hands on him for no reason. The patient complained he sustained scratches on the neck during the event and provided a physical description of the officer (but no name). The review included no chart review, no review of the schedule roster for the date matching the patient encounter, and no attempt to contact the complainant by mail correspondence.

Grievance file #8
On 4/30/13, the patient complained of the experience having surgery in the Ambulatory Surgery center. The patient was contacted and the bill was written off. There was no documentation of a written response provided . The case file was closed and while attachments were referenced, none were provided for review.

Grievance file #9
Patient ' s mother complained on 12/12/13 that the Emergency Department Medical Director threatened her with physical harm and calling the Police. No written letter of response was provided in accordance with hospital grievance policy.
Grievance file #10
The patient complained on 12/4/13 she waited in the ER for 11 hours with no asthma treatment in the emergency room . No written response was attached.

Grievance file #11:
On 1/15/14, a complaint was received from a patient ' s significant other who alleged the Security staff punched the patient in her chest following the patient ' s refusal to remove her jacket and that the jacket was ripped off by the staff. The grievance record provided during the survey contained no documentation of written letter of response provided to the complainant with findings, despite notation on a summary form that a response was provided. Attachments were referenced but not enclosed in the file provided. Follow up documents including a response letter were not provided by the facility until 2/11/14.
Grievance #12
On 1/16/14, a patient ' s sister complained the emergency room was too crowded with lack of privacy. The grievance record contained no written letter of response provided to the complainant with findings, despite notation in the grievance file that a response was provided. Attachments were referenced but not enclosed in the file provided. The case was closed on 1/17/14.

Grievance #13
On 10/2/14, the patient ' s daughter in law complained the patient was not provided with diabetic medication for more than eight hours in the emergency room. Outcome in grievance file notes patient/family " satisfied " ,that a response was given to the patient, and closed out on 10/7/13. However, there was no verification of documentation of a written response provided to the complainant in accordance with hospital policy.

Based on review of grievance records, procedures, and interviews with staff, it was determined that the hospital did not conform to facility procedures due to lack of complete documentation of investigation of grievance issues and thus did not fully resolve patient grievances.

Findings include:

Review of the hospital policy titled " Patient Complaint Grievance program " on 1/30/14 finds that the complaint issues shall be resolved by staff, reported to the departmental managers who will attempt to resolve the grievance, and also reported to Patient Relations departmental staff.

The facility did not conform to its own procedures because 9 of 13 grievance files reviewed on 1/30/14 did not include documentation of complete investigations as follows:

Grievance file #1
The file noted the patient complained on 7/10/13 that she waited 1 hour in the waiting room for chest pain. The security officer blocked her from entering to speak with the nurse and that he harassed her telling her he would throw her out and she would not be seen. The patient threw her cell phone at the security officer. An investigation was conducted by the hospital which included witness interviews with Security and nursing staff. It was concluded that while the patient was angry, the officer did not maintain professionalism and was counseled.
There was no investigation to determine if the patient ' s wait was excessive. Review of the patient ' s emergency record on 1/31/14 found that the patient was triaged at 9:37 PM on 7/3/14 with complaint of chest pain and classified as emergency severity index, ESI 2. The patient ' s EKG was timed at 9:14 PM and noted sinus tachycardia.
Review of the investigation file found that grievance information was not consistent with information that was documented in the patient's medical record reviewed. The grievance investigation did not address the length of the wait for triage. The investigation not address a finding for why the patient was ordered to have a security watch at 12:02 PM on 7/3/13 for purposes of psychiatric evaluation and that this obsevration was discontinued at 5:42 PM on 7/3/13. (which was more than nine hours prior to documented triage). At interview with the staff #2 on 1/31/14, no explanation could be provided for why the patient was placed on security watch 9 hours prior to medical triage.


Grievance file #2
Review of the grievance file on 1/29/14 found this patient ' s mother complained on 9/24/13 that her daughter was improperly cared for while in the psychiatric adolescent area in ED-3. It was alleged her daughter attempted to hurt herself twice and that staff were not watching her child. Medical and nursing staff reported the child was on continuous supervision but another hospital reviewer indicated an extra nursing attendant had started that week. The email responses did not address all the grievance concerns including the allegation that the patient was not bathed. The investigation did not evaluate or conclude if staff supervision was adequate.

Grievance file #3
A written complaint submitted by the partner of a patient who reported witnessing security staff punch another patient in the emergency room on 7/31/13. When reporting this situation, the complainant and her partner (the patient) were allegedly told to leave by the Nursing Director. The investigation file included a review by the Nursing Director of ED who reported the patient and complainant became threatening when the partner was asked to leave the emergency room with the other visitors until a situation involving a violent intoxicated patient was under control. A security department review was not submitted with the grievance file for review by the surveyor. The investigation did not evaluate if actions taken were appropriate with the violent patient, including a review of the patient's record.


Grievance file #6
Patient ' s family filed a complaint on 10/17/13 that the patient had been discharged from the emergency room wandering the street in a hospital gown. Additional complaints were filed about cleanliness in the emergency room during a return visit and that the ED Nursing Director Staff #2 was rude and pointed in the family ' s face. In the complaint file, the hospital reviewer described follow up which found there was a verbal interaction between the family member and the ED Nursing Director that required Security involvement. The nurse manager acknowledged the agency nurse who discharged the patient in a gown was dismissed. However, the grievance file contained documentation by the hospital's reviewer, who noted that it could not be substantiated that the patient had left in hospital gown. The reviewer did not address this inconsistency in findings obtained. The case was closed on 10/23/13 and there was no evidence the facility followed up on these contradictory findings noted about the manner in which the patient was dressed at discharge.


Grievance file #7
On 1/16/14 the patient complained a security officer placed his hands on him for no reason. The patient complained he sustained scratches on the neck during the event and provided a physical description of the officer (but no name was provided). Security Department review noted on 1/20/14 that an investigation could not be conducted due to insufficient detail provided and that two voice mails were left for the patient with no response. The review included no chart review, no review of the schedule roster for the date matching the patient encounter, and no attempt to contact the complainant by mail correspondence.

Grievance file #8
On 4/30/13, the patient complained of the experience having surgery in the Ambulatory Surgery center. He complained he was not assisted with a wheelchair by security, the nurse failed to provide pain medication, there was a excess delay on transport, the dietary meals was of poor quality, and about temperature control in that the room was too cold. The hospital review indicated the patient ' s report about the failure to assist with a wheelchair was inaccurate. While the dietary issue was addressed, the grievance file lacked follow up resolution of the transport issue. The record lacked follow up investigation of the pain medication issue.

Grievance file #10
The patient complained on 12/4/13 she waited in the ER for 11 hours with no asthma treatment in the emergency room. The grievance file contained actions taken to visit the patient who was anxious and who was receiving medication via mask and able to take medication. She was upset about waiting too long for a bed. On 12/5/13 the hospital staff visited the patient, who had been admitted and she was satisfied. Although the facility determined the patient was satisified, there was no notation by facility staff to address the potential delay in treatment.


Grievance file #12
On 1/16/14, a patient ' s sister complained the emergency room was too crowded with lack of privacy. She reported the stretchers are too close together and she requested transfer. The patient was requesting a breast pump. Staff noted situation is resolved but did not describe if the complaint was validated or describe actions taken other than provision of breast pump. The hospital representative followed up and acknowledged the patient ' s receipt of the pump and redirected medical concerns to her physician. The investigation lacked review of concerns about overcrowding and privacy.

Grievance file #13
On 10/2/14, the patient ' s daughter in law complained the patient was not provided with diabetic medication for more than eight hours in the emergency room. The complaint was referred to ED administrative staff including the Medical Director of Emergency, the evening supervisor, and to the Nursing Director of Emergency.
The administrator spoke with the husband and another relative, and reviewed the record for time and treatment. The patient and the family left the emergency department (ED) without signing out against medical advice (AMA). Outcome in file notes patient/family " satisfied ", that a response was given to the patient, and the complaint was closed out on 10/7/13. However, the investigative