HospitalInspections.org

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 .