HospitalInspections.org

Based on review of 1 of 4 hospital grievances (patient #1), review of Patient Rights and Grievance Process policy and procedures, and staff interviews, the hospital failed to adhere to their grievance policy by not: 1) providing a written response to patient #1 within one week of receipt of his grievance and 2) contacting patient #1 every 14 day until the grievance was resolved. Findings:

Review of the ED medical record revealed patient #1 was a 49 year-old who presented ambulatory to the ED on 7/10/2010 at 9:50 PM and in "fair" condition. Further review revealed patient #1 complained of an acute onset of pain in the right flank area that radiated to the right side of the back and abdomen. Documentation revealed the patient rated his pain as a 10 on a scale of 0-10 (0-no pain and 10-most painful). According to nursing documentation by S1 ED/RN at 9:55 patient #1's blood pressure was 168/96, heart rate 78 beats per minute, respirations 24 breaths per minute, temperature 98.3 degrees Fahrenheit and oxygen saturation 96 percent. The patient was triaged as non-emergent.

Review of the 7/10/2010 at 10:02 PM documentation revealed ED/Dr. S5 provided a medical screening examination. Further review revealed before patient #1 presented to the ED, he had eaten fish at a local fast food restaurant and began experiencing abdominal pains but denied having nausea, vomiting or diarrhea. Documentation revealed that the patient reported to Dr. S5 he had a bowel movement that day and denied any symptoms of a urinary tract infection. S5 documented in her findings that when she examined patient#1, his epigastric area was tender when palpated and there were no acute findings on examination of the patient.
Further documentation revealed on 7/10/2010 at 10:58 PM, S1 ED/RN administered Flexeril 10 mg (anti-inflammatory and muscle relaxant) and Ultram (analgesic) 50 mg by mouth to patient #1. S1 ED/RN documented that at 11:38 PM ED/Dr. S5 was in the exam room with patient #1 and the patient's pain was unrelieved. Continued review revealed S1 ED/RN documented that she gave patient #1 a GI cocktail 60 cc (Mylanta, Donnagel, Viscous Lidocaine) and 2 tablets of Levsin 0.125 mg (anticholinergic/antispasmodic) by mouth at 11:42 PM. According to the record at 11:35 PM the patient's blood pressure was 158/90, heart rate 80 beats per minute, respirations 22 breaths per minute. S1 also documented that she administered Simethicone (anti gas-forming agent) 80 mg 2 tablets by mouth at 12:04 AM on 7/11/10. She documented at that time the patient reported "just a little relief" from the medications. The nurse failed to rate the patient's pain at that time.

Review of the flat and upright abdominal radiology report for patient #1 dated 7/10/201 at 10:27 PM revealed, "The intestinal gas pattern is unremarkable. There are no abnormal masses or calcifications evident. There is no free air noted. Mild degenerative change of the lumbar spine. No pathological lesions are evident". Further review revealed the patient had a "normal abdomen".

Further review of the 7/11/2010 ED record revealed at 12:15 AM ED/Dr S5 told patient #1 that all his tests were normal and asked what he ate that night and he replied fish at a fast food restaurant earlier that evening. S5 documented that she told the patient she was going to discharge him home and to return to the ED if his symptoms worsened. S1 RN documented at 12:20 AM on 7/11/2010 that patient #1's blood pressure was 150/92, heart rate 64 beats per minute, respirations 22 breaths per minute, temperature 98 degrees Fahrenheit and 97 percent oxygen saturation.

Further documentation by RN S1 revealed at 12:24 AM patient #1 was still in some pain and she instructed him to increase his fluid intake, try to rest, follow-up with his primary care physician in 1 to 3 days and to return to the ED if his symptoms worsened. The medical record failed to reveal RNS1 rated the intensity of pain patient #1 was experiencing on discharge. Documentation revealed RNS1 further instructions the patient to avoid solid foods for 8 to 10 hours. According to the ED record patient #1 was discharged from the hospital in stable condition on 7/11/10 at 12:24 AM with his nephew.

Review of the 7/11/2010 ED record from Hospital A revealed patient #1 presented to the ED at 1:29 AM and was triaged by the ED/RN at 2:20 AM at an acuity level of 3 (non-urgent). According to nursing assessments documented by S1 ED/RN, patient #1 complained of right sided abdominal pain since 6:00 PM that evening and rated his pain at 10 on a numerical scale of 0-10. The nurse noted the patient reported his abdominal pain was sharp and constant.

Review of the vital signs obtained by the triage nurse at Hospital A revealed his temperature was 98.5 F, pulse 58 beats per minute, respirations 18 breaths per minute, oxygen saturation 95%, and blood pressure 172/99. The record indicated patient #1 weighed 361 pounds. His medical history included hypertension and his surgical history included left knee, jaw, and left hip.

The ED physician notes at Hospital A revealed patient #1 reported to him that his abdominal pain was constant and radiated to the right flank. The ED physician's examination revealed patient #1's abdomen was soft with mild right lower quadrant tenderness without guarding, negative rebound, the bowel sounds were normal and no mass was detected. The ED addressed in his notes that patient #1 was alert, in no acute distress, he did not appear anxious, his skin was warm and dry to touch and his oral mucosa was moist. The ED physician ordered lab studies and an abdominal and pelvis CT (computed tomography) scan with contrast. He also ordered Hydromorphone 1mg (narcotic analgesic) and Zofran 4mg (antiemetic) IV (intravenously) at 3:03 AM and the ED nurse established a Heparin lock to administer the medication and IV contrast for the CT scan.

Review of the results of the 7/11/2010 at 5:08 AM abdominal and pelvic CT scan with a preliminary report by the radiologist at that time, revealed patient #1 had a large cystic mesenteric mass in the right mid abdomen. The radiologist noted the differential diagnosis of the mass included a mesenteric cyst, an enteric duplication cyst, a chronic resolving hematoma/seroma, or a pancreatic pseudocysts although there was "no
obvious evidence of prior pancreatitis and much less likely a cystic neoplasm". The radiology report also indicated that the patient had a left renal cyst and extensive degenerative disc disease in the lumbar spine. The pelvic CT scan was negative except for the cystic mesenteric mass.


Further review of ED physician's notes at Hospital A revealed at 5:50 AM he (the ED physician) discussed the CT findings with the radiologist,
"There is a 7.5x8.0 cystic mass in the right pelvis". The physician noted in the ED record he talked with patient #1 about the CT results and that admission to the hospital would be necessary. Further review revealed the ED physician indicated that he contacted a local surgeon at 5:46 AM, but patient #1 wanted to be discharged and agreed to follow up with the surgeon. The ED physician documented that he gave patient #1 printed material regarding pelvic masses and abdominal pain, a prescription for Lortab (analgesic) with instructions to see his primary care physician at the next available time. The patient was discharged from Hospital A at 6:03 AM. The ED clerk stated the ED physician who examined patient #1 was no longer working at Hospital A and she did not have a contact number for the physician.

In an interview on 10/21/2010 at 1:58 PM S2 RN Risk Manager reported she had worked at Richland Parish Hospital for 15 years. She stated patient #1 came to the rural health clinic adjacent to the hospital to file a grievance against the ED and Dr. S5 and that she spoke with the patient and documented his grievance as he verbalized it to her. S2 stated patient #1 told her that he saw Dr. S5 in the ED and felt that he did not receive medication for his pain, that the physician was rude to him and that she had told him nothing was wrong with him. S2RN further stated that patient #1 gave her a copy of the CT scan from Hospital A where he presented after receiving treatment in the ED at Richland Parish Hospital on 7/10/2010. S2 reported the patient told her that he was treated in the ED at Hospital A and discharged. S2 indicated that patient #1 also told her that the ED physician at Hospital A told him that he needed emergency surgery, but when she talked with the patient two weeks ago (no documentation of date) he had not undergone any type of surgical procedure.

S2 RN further stated that patient #1 questioned why the ED physician did not detect the abdominal cyst on his x-rays at Richland Parish Hospital. S2 said she told the patient that they did not have a CT scanner at their hospital and that they only did a flat and erect of the abdomen which would not detect his problem. S2 RN stated patient #1 was "very nice" but he told her that 3 years ago he filed another grievance against ED/Dr. S5 and nothing was done about it. S2 indicated she asked the patient who he spoke with to file that complaint and he named a person who had never worked at the hospital. S2 further indicated that she did not have documented evidence of the complaint.

Further interview with S2 revealed she failed to document the day patient #1 filed his grievance but she estimated the date as 8/10/2010. She said she pulled the ED record as well as the record of the patient's ED visit in 2007. S2 said after reviewing the records she interviewed the ED/RN and asked her to submit a written account of the ED visit. S2 acknowledged she probably had not followed the time lines of the hospital grievance policy to provide a written response to the patient, but she was waiting for Dr. S6 to complete her review of the medical record. S2RN reported she called patient #1 at his mother's telephone number which she got from the face sheet of the patient's ED record. S2 said patient #1 asked her not to call him at that number again.

Review of the grievance by patient #1 which was documented by S2 revealed patient #1 reported to her that he presented to the ED on 7/11/2010 at approximately 9:00 PM with severe pain in the right abdomen. Further review revealed a female physician (Dr. S5) performed a medical screening examination and ordered x-rays, lab studies and a urinalysis. Documentation of the grievance also indicated that patient #1 reported he received an injection, a GI Cocktail and other medication by mouth for pain.

Further review of the grievance revealed patient #1 reported that his pain was not relieved upon discharge from the ED and that he felt his pain had worsened. The documentation indicated that ED/Dr. S5 told him "He was acting, He is in no pain". The complainant reported that someone (did not document who) told patient #1"if pain returns, go to the big hospital". The complainant further addressed that after being discharged from Richland Parish Hospital, his nephew started driving him (patient #1) to Hospital A (an acute care hospital about 40 miles away) and before they arrived his nephew had to stop the car to allow him to "walk off his pain". S2 documented that patient #1 reported to her that he arrived at the ED at Hospital A around 11:00 PM and staff performed a CT (computed tomography) scan that indicated he had a "mass size of tumor". Further review revealed patient #1 indicated that he was not discharged from Hospital A until 6:00 AM and that they scheduled him for surgery Monday August 16, 2010.

Review of the 8/12/2010 (no time documented) documentation signed by S2 RN Risk Manager regarding the investigation of patient #1's grievance, revealed she went to the ED that night to speak with S1 ED/RN who worked on 7/10/2010 when patient #1 presented to the ED at Richland Parish Hospital. S2 documented that she gave S1 ED/RN patient #1's 7/10/2010 ED record and asked her to review it. She also requested S2 RN to record any information about the patient's visit and his response to the treatment that he received. Review of the form titled "Authorization to Release Information" revealed on 8/17/2010 (no time documented) patient #1 signed a form requesting the release of his medical record.

Review of the written statement by S1 ED/RN dated 8/21/2010 (not timed and dated and 11 days after S2 requested her to write her account of patient #1's ED visit) concerning patient #1's ED visit revealed she recalled the patient presented with severe abdominal pain and that lab and x-rays were ordered. S1 noted that she administered oral medications and an injection for the patient and that the patient did have some relief from the medications. Further review of the document revealed S1 noted that ED/Dr. S5 explained to patient #1 that all his tests done at Richland Parish Hospital were within normal limits and instructed the patient to avoid solid foods for a while because he was complaining of pain after eating, to follow up with his primary care physician, or to return to the ED if his symptoms worsened. S1 documented after patient #1" received exit care", he stated that he still had some pain (and) asked about going to Hospital A (about 40 miles away). S1 noted that she told the patient that was his choice to do that and he left in stable condition with his nephew.

Further review of the investigation of the grievance by S2 RN Risk Manager revealed on 8/23/2010 (not timed) that she spoke with Dr. S6 ED Medical Director in a medical staff meeting about the grievance filed by patient #1. S2 noted that Dr. S6 agreed to review patient #1's medical record as part of peer review and discuss the case with ED/Dr. S5.

Review of hospital policy "Standard #1 Notice of Patient Rights and Grievances" revealed a patient grievance should be recorded on the Grievance/Resolution Form and that the department head, or supervisor receiving the written grievance should investigate, evaluate and provide a solution or explanation to the grievance. The policy indicated that a written response from the department head (or Administration when deemed necessary) would be given to the complainant within one week. Further review revealed in the event a resolution is not reached, a hospital designee will contact the complainant every 14 working days (excludes holidays and weekends) and when completed, send a written response to the complainant. According to the policy, once the investigation is complete the patient should receive a written response which includes steps taken to investigate the grievance and the results of the process.

During the survey S2 RN Risk Manager failed to provide the survey team with documentation that a response letter was sent to the patient regarding his grievance. There also failed to be documentation in the investigative report by S2 that she had spoken with patient #1 since he filed the complaint.

In an interview on 10/21/2010 at 2:15 PM the DON (director of nursing services) stated the S2 RN Risk Manager informed her of the grievance voiced by patient #1. She stated she did not participate in the investigation but she knew that Dr. S7 (Chief of Staff at Richland Parish Hospital) had written a letter regarding his findings and they were waiting for ED/Dr. S5 to complete her written response before submitting the information to the quality agency where patient #1 had filed a written response. The survey team was unable to interview Dr S7 and the hospital failed to provide a letter from Dr S7 regarding his investigation to the allegations by patient #1. The DON stated she attempted several times to contact him but he was out of town.