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Based on observation, interview and record review, the facility failed to protect the rights of two (pts. #1 and #2) of five patients in failing to log and respond to grievances resulting in the loss of rights to submit and have grievances addressed by all patients submitting a complaint/grievance. Findings include:

1. The facility failed to log all grievances received by the facility and failed to follow policy for the process of addressing grievances received by the facility. (See specific tag A-0118)

Based on observation, interview, and document review the facility failed to log and follow policy for two of five patients (#1 and #2) reporting grievances received by the facility resulting in the potential denial of all patients to have grievances investigated and addressed by the facility. Findings include:

On 11/16/2021 at 1440 during tour of the facility, staff B the Director of Nursing stated she was aware of a grievance received by the facility recently and she presumed they might be related to the reason for the survey. Staff B was asked to produce all documentation for the grievance.

On 11/16/2021 at 1530, staff B provided documentation for a grievance received on 8/19/2021. Staff C stated the grievance was received via the Marketing Department. The grievance received was concerning the patient (patient #1) of the complaint. Staff B was queried if an investigation was completed and if a written response was provided to the complainant of the grievance. Staff B stated, "We have been without a patient experience person since 8/6/2021 and that the facility has struggled with answering grievances since the loss of the patient experience person."

On 11/16/2021 Staff B was then asked if there was any other grievances received by the facility that may not have been on the grievance log. Staff B explained, "I have one other complaint that I have been in contact with that the complainant (patient #2) wouldn't give me her name...I did finally convince her to give me her first name but that was all she would provide." Staff B was asked if the complaint was logged. Staff B responded, "No...I didn't have her last name to log the complaint." Staff C confirmed that the grievance received via phone had not been formally responded to as she didn't have the complainant's address.

On 11/17/2021 at 1040 a document review of the complaints and grievance log was conducted. Three complaints/grievances were reviewed. The log failed to have the two grievances received by the facility. Staff B provided the written grievance received and information from 8/19/2021 ED visit. Staff B was queried if an investigation had been conducted. Staff B stated the grievance was shared with the Manager of the Emergency Department, Staff C.

On 11/17/2021 at 1100, Staff C was asked if an investigation was conducted concerning the grievance from 8/19/2021. Staff C stated that the grievance was discussed with the Medical Director of ED, Staff K. Staff C was asked if the grievance received a written response to her grievance. Staff C responded, "No...Not that I know of."

On 11/18/2021 at 1000 a document review was conducted of the policy titled, "Patient Complaint and Grievance Policy," policy number MHC_SE004 dated 9/1/2021. According the the policy it states, " 3.2 Grievance - A written or verbal expression of dissatisfaction with the resolution of a complaint or communication received after discharge. This does include allegations of abuse, neglect, or harm. Any allegation of abuse, neglect or harm ordinarily shall be elevated to a grievance and the process ordinarily shall begin for investigation. A grievance ordinarily requires a written response to the patient. A grievance is ordinarily shall also be defined as:
3.2.1. Instances where the Patient Experience Department, staff, and/or management is contacted after failure to resolve initial complaint.
3.2.2. Any written complaint including email, or fax.
3.2.3. A written complaint attached to a patient experience survey that specifically
requests resolution and includes patient name and contact information.
3.2.4. Any request from a patient or patient representative that requests their
complaint be handled as a grievance.
3.2.5. A Medicare beneficiary billing complaint related to rights and limitations
including, for example, complaints regarding allowable charges or allowable deductible
charges.
3.2.5.1. Note that billing concerns outside of Medicare's rights and limitations
ordinarily are not considered complaints/grievances.
3.2.6. Any complaint verbal or in writing regarding the hospital's compliance with
CMS Hospital Conditions of Participation (CoPs)."

Further review of the policy states, "5.2. Grievances:
5.2.1. All grievances ordinarily shall be documented within McLaren Safety First
under the Feedback module. Documentation ordinarily shall include the allegation as
stated by the patient/representative, a summary of the investigation, the actions taken to
resolve the complaint, date of completion, date(s)/time(s) of verbal and written
communications, and the attached document(s) of written response.
5.2.2. All grievances ordinarily shall require a written response to the
patient/representative acknowledging receipt of the complaint/concern within 7 calendar
days of original receipt. The response ordinarily shall be written in clear and easily
understandable language, and tailored to the complainant ' s age, language, and ability to
understand.
5.2.3. A second written communication will be sent to the patient/representative
outlining the resolution of the grievance upon completion within a reasonable time
frame, but no longer than 30 calendar days.
5.2.4. If the grievance will not be resolved within the initial 30 calendar day time
line, the patient/representative ordinarily shall receive written communication that the
hospital or medical practice is still working to resolve the concern and identify the
number of days before a response should be expected.
5.2.5. Any written response to the patient/representative ordinarily shall contain the
following information:
5.2.5.1. The name of the hospital or medical practice contact person;
5.2.5.2. The steps taken on behalf of the patient to investigate the grievance;
5.2.5.3. The results of the grievance process; and,
5.2.5.4. The date of completion
5.2.6. The Patient Grievance Committee ordinarily shall review and follow up if
patient/representative requests additional review or chooses to appeal after receiving
their grievance closure letter.
5.3. If the patient chooses to appeal their written closure letter, the Patient Grievance
Committee ordinarily shall be made aware of the request for a formal grievance review
verbally or in writing. The patient ' s appeal request ordinarily shall include the reason
why the resolution is not satisfactory and what would be considered a satisfactory result.
5.3.1. The Patient Grievance Committee ordinarily shall review the grievance,
investigation, and closure summary. The findings of the Committee ' s review ordinarily
shall be communicated in writing to the patient within 30 days of the request for appeal.
5.4. Grievances ordinarily shall be reported to the Board of Trustees at least annually.
5.5. Special Circumstances
5.5.1. If the concern of the patient/representative involves an allegation of
malpractice or negligence, the issue ordinarily shall also be immediately referred to
Clinical Risk and Patient Safety, including entry in McLaren Safety First.
5.5.2. If the concerns of the patient/representative involve a HIPAA violation, the
concern ordinarily shall also be forwarded to the Compliance Department for
investigation and resolution.
5.5.3. If the patient/representative requests further avenues to dispute the
resolution, this information is posted at the entrances of all facilities. Refer to Appendix
7.2.
5.5.4. Lost/stolen ordinarily shall not be considered a complaint or grievance and
ordinarily shall be excluded from the provisions of this policy."

Based on interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to complete an appropriate medical screening exam on 2 of 24 patients (#1 and #2) and failed to explain the risks of transfer to another facility to the patient /guardian/responsible party for 4 of 5 patients (# 20, #,21, #22, and #24) resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

1. The failure to complete an appropriate medical screening exam. (See tag A-2406)
2. The failure to explain the risk of transfer of a patient from one facility to another facility for care. (See tag A-2409)

Based on observation and interview the facility failed to ensure Emergency Medical Treatment And Labor Act (EMTALA) signs in waiting room areas were likely to be noticed by all individuals that visit the Emergency Department (ED) resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 11/16/2021 at 1340 during the initial tour of the ED waiting room areas it was revealed the facility failed to have EMTALA signage posted in three areas designated as waiting room areas for patients. Further survey of the registration area revealed EMTALA signage which was blocked from view by a facility poster sign. The signage was approximately eight inches wide by ten inches long mixed within various other signage making the sign unable to be seen readily.

On 11/16/2021 at 1345 it was revealed the signage at the ambulance bay entry area was inconspicuous and not easily visible to patients entering the facility.

On 11/16/2021 at 1346 staff C (the Vice President and Director of Nursing) was queried regarding required EMTALA signage and if the signage was appropriately sized for visibility and likely to be noticed by all individuals that visit the ED. Staff C responded, "I understand and we will get it corrected immediately."

Based on document review, interview, and policy review the facility failed to log 1 of 24 (#2) patients presenting to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients leaving the facility without being seen for emergency services and the potential for less than optimal outcomes. Findings include:

On 11/17/2021 at 0900 during document review of the ED log from May 16, 2021 through November 16, 2021 it was revealed patient #2 was not part of the ED log for the day the patient presented to the ED on 10/19/2021. Staff C (the ED Manager) was queried if there were any individuals that had presented to the ED that may not be logged. Staff C stated that patient #2 had presented to the ED on 10/19/2021 but had refused to provide her name after she had been asked to abide by the facility mask protocol. Staff C was queried if the mask protocol superseded the patient's reason for seeking out emergent medical treatment. Staff B (Vice President and Director of Nursing) responded to the question in lieu of staff A and stated, "We are in a quandary because we are trying to follow OSHA (Occupational Safety and Health Administration) guidelines as well..."

On 11/18/2021 at 1300 a document review of the policy titled, ""EMTALA: Treatment of
Emergency Medical Conditions and Patient Transfers," policy number MHC_CC0125, revised date of June 15, 2020. The policy states the following, "3.6. Emergency Medical Care/EMTALA Log (Log) is defined as a record of patients seeking emergency medical services at Hospital."

Based on interview and document review the facility failed to complete an appropriate medical screening exam for two (#1, #2) of 24 patients reviewed for treatment and medical screening presenting to the Emergency Department (ED) resulting in the potential to delay care and less than optimal patient outcomes. Findings include:

On 11/16/2021 at 1440 it was revealed a patient (#2) arrived to the ED on 10/19/2021 and had left the ED after being asked to wear a mask.

On 11/17/2021 at 1245 an interview occurred with staff O, the patient access representative on 10/19/2021. Staff O was queried about patient #2 arriving at the ED for emergency services. Staff O stated the patient #2 refused to wear a mask in order to be seen in the ED. Staff O was asked why the patient (#2) had presented to the ED. Staff O stated that she remembered that the patient had stated that she was possibly pregnant and thought she might have been experiencing problems. Staff O was asked if the patient was triaged and if she had a medical screening exam. Staff O stated that since the patient was unwilling to comply with wearing a mask that the patient left the facility without being triaged or having a medical screening exam. Staff O was then queried if there was an alternative to wearing a mask for individuals presenting to the ED. Staff O stated, "They can wear a face shield if they provide a doctor's note stating they could not wear a mask."

Video requested from the ED for 10/19/2021 at 1730 to 1800 was provided. Document review of the video occurred on 11/17/2021 at 1500. During the document review of the video footage of 10/19/2021 at 1740 it was revealed patient #2 entered the facility and stopped at the greeter's station. Patient #2 was observed presenting to the registration area and conversing with someone behind the glass partition. The patient was then seen going back to the vestibule where the greeter's station is located and returning to the registration area. The patient (#2) was accompanied by two additional people (a male and a female). At 1743 the patient stood up and took her mask off, which was located below her nose and threw the mask in the garbage.

On 11/18/2021 at 1300 a document review occurred of the policy titled, ""EMTALA: Treatment of
Emergency Medical Conditions and Patient Transfers," policy number MHC_CC0125, revised date of June 15, 2020. According to the policy it states the following:

"5.1. Medical Screening Exam.
5.1.1. An MSE is required when an individual:
5.1.1.1. Presents to the Hospital ' s Emergency Department, Labor & Delivery
Department, or be anywhere on Hospital Property requesting emergency medical
services.
5.1.2. Performing the MSE. The MSE will be performed:
5.1.2.1. By a Qualified Medical Professional.
5.1.2.2. In the Department within the Hospital identified as appropriate to address
the patient ' s chief complaint, including:
5.1.2.2.1. The Emergency Department
5.1.2.2.2. The Labor & Delivery Department
5.1.2.2.3. Psychiatric Unit (if Hospital has a unit)
5.1.2.2.4. Other department that the Hospital identifies as providing
emergency care.
5.1.3. Scope of MSE. The MSE will generally consist of inquiry, examination and
ancillary tests based on the patient ' s chief complaint (within the capability of the
department conducting the MSE) of those medical conditions and factors which, in the
exercise of professional judgment are indicative of an emergency medical condition.
5.1.4. Documenting the MSE. The QMP will document within the patient ' s medical
record:
5.1.4.1. The findings of the MSE and any other analysis used to determine
whether or not an emergency medical condition exists.
5.1.4.2. Evidence of the continued monitoring of the patient ' s needs and
treatment provided, continuing until the patient is either stabilized or appropriately
transferred.
5.1.4.3. The disposition of the patient, with support for the decision, including if
the patient leaves AMA or LBT.
5.1.4.4. Education provided to the patient.
5.1.4.5. The plan for follow-up care, as appropriate.
5.2. Treatment. Hospital will provide care until the treating physician determines that
an emergency medical condition does not exist, the patient is Stable for Discharge, or
the patient is Stable for Transfer."


45245

On 11/17/21 at 1048 a review of the Emergency Department record of patient (Pt) #1 was conducted. Review of the Emergency Department (ED) log for 08/12/21 documented Pt. #1 as an 8-year-old Caucasian male who arrived at 1405 with parent (mother) complaining of (Pt.#1's) "lethargy and not eating-mother positive for covid 11 days ago" Patient #1 was assigned an ESI (emergency severity index triage acuity scale) of 3 (urgent).

Document review revealed a note dated 08/12/21 at 1354 by ED triage Registered Nurse (RN) Staff L documented triage assessment that included the following vital signs.

Temperature Oral: 36.4 Deg C (converted to ;97.5 Deg F)
Heart Rate Monitored: 109 BPM (HI)
Respiratory Rate: 22 br/min
SpO2: 98%
Oxygen therapy: Room Air
Systolic Blood Pressure: 118 mmHg
Diastolic Blood Pressure: 69 mmHg
Height/Length: 135 cm (Converted to : 4 FT 5 IN)
Weight Admission: 24.9 Kg (Converted to: 54 LB 14OZ)
Pain assessment noted as "Denies pain/discomfort"

Further review revealed a second assessment of vital signs that occurred 5 hours and 7 minutes later, as the patient was prepared for discharge home. Discharge vital signs were all within normal limits. No other documentation is present indicating Pt.#1's progress nor the location where Pt.#1 was treated.

Review of document "Emergency Room Report" dated 08/12/21 lists Staff N as Pt. #1's attending physician. The report begins with an Addendum dated 08/14/21 at 0922, authored by Staff N, and reads as follows:

" called the mother back on 08/14/21 to check on the child. Mother informed me that the child appeared to be getting sicker instead of coming back to the emergency department she went to (Facility B) Medical Center (where) the child was diagnosed with DKA (diabetic keto-acidosis). Is no family history of diabetes. Patient was not having any nausea vomiting for our visit. Nor was he having any significant urinary symptoms. The case had also been discussed with Dr. (Staff M) and she was apprised of the patient's up-to-date as well."

Chief Complaint-Fatigue

History of Present Illness
"This 80-year-old (8-year-old) child presents with mother. Mother is concerned because the child's been having fatigue for about the last week. She called her doctor yesterday and they told her they could see her by video appointment Friday. She has had no fever no cough no complaints of chest pain but the mother feels a CT scan of breathing a little harder than he normally does not wheezing no nausea vomiting not eating much but drinking no complaints of about pain or back pain sore throat no diarrhea no constipation no leg pain no rashes again plenty of fluids and urinating okay. The mother had Covid last Monday has been symptom free for last 4 days again the child's been sick for a week or little longer mother is not immunized against Covid. No complaints of headache neck pain blurry vision double vision balance or coordination issues."

Medical Decision Making
"The child is fatigued but has no other complaints or symptoms and is hemodynamically stable. Covid test is performed. The mother is worried about his weight loss he does not seem to be excessively cachectic to me I told the mother that hydration right now is his primary the most important and that maybe she could supplement his water with some protein shakes or liquid nutrition. Case discussed with the pediatric hospitalist (Staff M) who recommended the same kind of things and did not recommend any specific particular testing or any other testing or any other recommendations."
Diagnosis
Fatigue and weakness of uncertain etiology
Covid positivity

Review of Laboratory Orders for Pt.#1 on 08/12/21 shows an order was placed for a "19 CoV-2 RNA Rapid" (Covid test) at 16:43. No additional diagnostic studies were ordered.

On 11/17/21 at 12:37 a phone interview was conducted with attending physician Staff N. Staff N was queried of his recollection of the encounter with Pt.#1, Staff N stated "I did see them in Express Care. She was concerned that the child was sick." Staff N was then queried if there was any indication for additional diagnostic testing, to which he replied "My evaluation didn't reveal anything other than he was Covid positive. I received a phone call which recommends Pediatric consult, and no further lab testing." Staff N was then questioned if the patient's mother appeared upset with the decision to forego further testing. Staff N stated "I don't remember if she was upset. Yes, I do recall she wrote a complaint. We had discussed it. I called her two days later, so I called to check on how the child was doing, she took him to (Facility)."

On 11/17/21 at 1315 an interview was conducted with Staff Q, the ED registered nurse that provided care to patient #1. Staff Q was queried if she was aware that the parent of patient #1 who was present at the time of the ED visit had additional concerns prior to discharge. Staff Q replied, "The child's mother did communicate that she wanted further testing at which time I did have a conversation with the provider." Staff Q was then asked if any additional testing was ordered. Staff Q stated, "No ...no additional testing was ordered."

On 11/17/21 at 1400 a phone interview was conducted with the consulting Pediatric physician, (Staff M). Staff M was queried about the consultation, stating "He called and wanted to discuss findings, which were otherwise stable. He felt he was stable." Staff M was questioned if she had any recommendations for treatment, replying "I didn't suggest any labs. I did remember asking about the pulse ox, he said it was fine." Staff M was asked if it would be 'normal' to do lab studies in this particular case, to which she stated, "No." When asked if a Covid test would be 'normal' in this case, she stated, "Yes." Staff M was queried what would be the minimum workup for a Medical Screening Exam (MSE), Staff M replied, "Pulse Ox, head-to-toe, Neuro's, Electrolytes. He was quote tired, so that doesn't raise it to another level."

Further document review of "I-Net Documentation" dated 08/12/21@1840 revealed that a nursing assessment of Pt.#1 was completed by Staff L. Pt. # 1's condition was listed as "improved" and was discharged home at 19:12 on 08/12/21.

Review of the medical record for patient #1 from Facility B on 11/17/21 at 0900, revealed that Pt #1, was transported to Facility B's ED by ambulance the following morning (08/13/21). These records revealed Pt #1 was assessed in Facility B's ED and diagnosed with severe Diabetic Ketoacidosis. Pt #1 was admitted to the Facility B for continuing treatment.

Based on interview and document review, the facility failed to explain and document the risk of transfer for 4 of 5 patients (#20,#21,#22, and #24) reviewed for transfer prior to transferring the patient resulting in the potential for unsatisfactory outcomes. Findings include:

On 11/18/2021 at 1030 during the document review of patient #20's medical record it was revealed the transfer form did not have risks listed on the transfer form. On 11/18/2021 Staff C, the Emergency Department (ED) Manager, confirmed the findings.

On 11/18/2021 at 1040 during the document review of patient #21's medical record it was revealed the transfer form did not have risks listed on the transfer form. On 11/18/2021 at 1045 Staff C, the ED Manager, confirmed the findings.

On 11/18/2021 at 1050 during the document review of patient #22's medical record it was revealed the transfer form did not have risks listed on the transfer form. On 11/18/2021 at 1055 Staff C, the ED Manager, confirmed the findings.

On 11/18/2021 at 1115 during the document review of patient #24's medical record it was revealed the transfer form did not have risks listed on the transfer form. On 11/18/2021 at 1120 Staff C, the ED Manager, confirmed the findings.

On 11/18/2021 at 1120 an interview occurred with Staff C. Staff C was queried why the transfer forms failed to have "risks" explained to the patient or guardian. Staff C responded, "I know they (the providers) document in their notes that risks are explained to the patient or guardian but it looks as though they don't fill the risk portion out on the forms."

On 11/18/2021 at 1300 a document review occurred of the policy titled, "EMTALA: Treatment of
Emergency Medical Conditions and Patient Transfers," policy number MHC_CC0125, revised date of June 15, 2020. According to the policy it states, " 3.21.4. The QMP (Qualified Medical Professional) has informed the patient of the risks and benefits of the transfer."