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1401 EAST STATE STREET

ROCKFORD, IL 61104

PATIENT RIGHTS: REVIEW OF GRIEVANCES

Tag No.: A0119

Based on document review and interview, it was determined that for 1 of 4 (Pt. #2) files reviewed for grievances, the Hospital failed to ensure that the grievance process was followed by not investigating and providing a prompt resolution to a patient grievance.

Findings include:

1. On 9/28/2021, the Hospital's policy titled, "Patient Complaint and Grievance" dated 3/9/2021, was reviewed. The policy required, "...VI. Practice A. Definitions...2. Grievance (Defined by CMS Conditions of Participation) Any verbal concern which is a) not resolved by the staff present; b) postponed for later resolution; c) requires investigation; and/or d) requires further action for resolution, becomes a grievance. a) All written complaints regarding patient care, i.e., letters, comment cards, emails, and faxes, are considered to be grievances, whether from an inpatient, outpatient, released/discharged patient or their representative....viii General Grievance Response Guidelines - A. Reasonable effort should be made to resolve and respond to all patient grievances in a timely manner, to achieve compliance with CMS Conditions of Participation...D. Grievances will be thoroughly investigated by: 1. A review of the patient/family's perceptions of the incident. 2. A review of all related records (medical and/or billing). 3. Interviews with the staff and caregivers involved in the incident or as described in the patient's grievance. 4. Once the investigation is complete, the patient/family should receive written notice of any findings..."

2. On 9/27/2021, Pt. #2's clinical records were reviewed and included the following:
-Pt. #2 was admitted to a medical unit on 4/20/2021, with the diagnoses of severe sepsis (infection in the blood stream that causes low blood pressure, elevated heart rate and fever), neutropenic fever (high temperature in patients with low neutrophil blood cells) and c-diff (clostridium difficile- infection in the large intestines) diarrhea. Pt. #2 was discharged home with home health care on 4/26/2021.
-Pt. #2 was admitted on 5/2/2021 with the diagnoses of hypomagnesemia (low magnesium) and acute deep vein thrombosis (DVT) of popliteal vein of left lower extremity, and was discharged home with home health care on 5/24/2021.

3. On 9/28/2021, an email dated 6/4/2021, from Pt. #2's daughter was presented by Hospital staff. The email included 4 pages of a detailed grievance related to labs, infection, inappropriate discharge and mistreatment from staff while in the hospital in April 2021 and May 2021. The email included specific incidents with dates and staff names. The email also included a request for the hospital to act on the concerns in the complaint. The Hospital's email response to Pt. #2 daughter's complaint, dated 6/7/2021, included an attached grievance form, a telephone number to the Office of Civil Rights, a request for more information about a hospital acquired injury, a telephone number to the hospital's medical records department to gather more information, and an offer to forward the concerns to the legal/risk department once Pt. #2 gathered more details regarding her concerns.

-The Hospital failed to provide evidence that Pt. #2's grievance was investigated and/or a resolution was met and sent to Pt. #2 or Pt. #2's representative.

4. On 9/28/2021 at 9:17 AM, an interview was conducted with the Director of Patient and Family Experience (E #21). E #21 stated that Pt. #2 and her daughter have complained in the past about nursing care, food, and physician communication. E #21 stated that the issues have been resolved at the point of service. E #21 stated that a few months ago Pt. #2's daughter sent a lengthy email to Hospital staff complaining about multiple issues. E #21 stated that the Hospital sent an email response to Pt. #2's daughter with an attached official grievance form so that Pt. #2's daughter could file an official grievance on the form. E #21 stated that the complaint received by Pt. #2's daughter was not documented in the Hospital's electronic grievance/complaint system because Pt. #2 or Pt. #2's daughter did not submit the grievance form. E #21 stated that he is not aware of any further contact with Pt. #2's daughter or of an investigation related to the grievance being conducted by the Hospital.

DISCHARGE PLANNING- TRANSMISSION INFORMATION

Tag No.: A0813

Based on document review and interview, it was determined that for 1 of 4 (Pt #3) clinical records reviewed for discharge planning, the Hospital failed to ensure that the patient was transferred, along with the necessary medical information pertaining to the patient's current course of treatment, at the time of transfer.


Findings include:

1. The Hospital's policy titled, "Transfer to Other Facility's", (dated 10/26/2020), was reviewed on 9/29/2021, and required, " Upon knowledge of or planning to another facility, acute or long term, the patient will be consulted and informed consent will be obtained prior to transfer ...If the transfer is to another acute care/tertiary care hospital, the [Hospital] physician requesting transfer must arrange for an accepting physician at the receiving hospital prior to the completion of any other transfer arrangements. The receiving facility has available space and qualified personnel for treatment of the patient. The receiving facility has agreed to accept the patient and agrees to provide appropriate medical treatment. Copies of appropriate medical records of examination and treatment will be sent with the patient. A transfer form will be completed on all patients transferred from any patient care area at [Hospital] to another facility."

2. The clinical record for Pt #3 was reviewed on 9/27/2021. Pt #3 presented to the ED (emergency department) on 4/11/2021 at 8:21 PM, with a chief complaint of ETOH (intoxication/excessive alcohol).

- ED Triage Note (dated 4/11/2021 at 9:17 PM), included, "Patient arrives with a chief complaint of ETOH. Pt states that he wants to detox [abrupt cessation of alcohol intake] ...Pt appears intoxicated ...Patient is accompanied by self."

- HPI (History of Present Illness), documented by the ED Physician (MD #3), dated 4/12/21 at 10:18 PM, included, "Patient ...presents requesting admission for detox from alcohol ...Patient reports multiple attempts with both inpatient and outpatient treatment, but continues to abuse alcohol ...The patient is intoxicated now, reports drinking throughout the day, and would like to be admitted for detox at this facility. Patient reports he is beginning to withdrawal ..."

- ED Note (dated 4/12/2021 at 12:14 AM), documented by the Sobriety Counselor (E #8), included, "Met with patient at the request of provider. Patient reports he is looking for detox and a long-term treatment facility. Patient does not have insurance or transportation. [Program for sobriety] spoke with [receiving local Hospital], they are waiting for him to arrive in their ED for detox. Providers are working on assisting with transportation. [Program for sobriety] will follow up with patient following discharge ..."

- ED note documented by the ED Registered Nurse (E #7), dated 4/12/2021 at 12:30 AM), included, "Transportation arranged for patient per notification from [Sobriety Program], [E #8], that patient has been accepted to [receiving Hospital] to the ED department for treatment."

The clinical record did not include that Pt #3's medical information or medical record was sent with the patient to the recieving hospital at the time of transfer.

3. On 9/28/2021 at 8:45 AM, an interview was conducted with the ED RN (E #7). E #7 stated that Pt #3 was working with the Sobriety Program Counselor (E #8) while in the ED (on 4/11/2021). E #7 stated that E #8 (Sobriety Coach) told E #7 that he found a place for Pt #3 that offers inpatient detox. E #7 stated that she set up the ambulance for Pt #3. E #7 stated that E #8 told her that Pt #3 was discharged, and she did not know that Pt #3 was actually being transferred to another ED. E #7 stated that when Pt #3 was transported from the ED, the patient was sent with the "After Visit Summary", however there was no medical history sent with Pt #3.