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Based on record review and interview, the facility failed to promptly resolve grievances for 3 of 10 patients reviewed (#'s 2, 9, 11) who left AMA (Against Medical Advice) with complaints about their care.

- Patient #2 informed RN #60 on 5E on 9/8/14 at 11:36 p.m. of her dissatisfaction with her care in the Emergency Department (ED) that evening. She then left the hospital AMA. No grievance report was initiated.

-Patient #9 left the hospital AMA on 11/9/14 after be admitted to ICU (Intensive Care Unit) for 2 days. RN #69 wrote the patient stated he wanted to go home because he was not treated well in the hospital. No grievance report was initiated.

-Patient #11 left the hospital AMA on 11/11/14 after being admitted to 6E for 4 days. He wrote on the AMA record that he was leaving because he had been "mis-dosed." RN #70 was his nurse at that time. No grievance report was initiated.

Complaint #TX00204341

Findings include:

Patient #2

Phone interview on 11/18/14 at 8:06 a.m. with Patient #2, she said she had gone to the facility's ED (Emergency Department) on 9/8/14 because she was having a severe headache. She said she had had a myelogram on 9/5/14 and they told her if she experienced a headache, nausea or vomiting to go to the ED department because she could be having a spinal fluid leak. She said while she was in the ED the physician decided not to treat the spinal leak. He told her she could get a pain shot now and go home or she could stay the night and get a blood patch done in the morning. She was then given Benadryl and Compazine for her migraine headache by the nurse. She said she told the nurse she had a history of migraine headaches and this was not a migraine. The nurse gave the medication anyway. Patient #2 said she was then taken to her room and began to react to the Compazine. She said she told the nurse on the floor she was having a reaction and was told by the nurse it was all in her head. She said she made a complaint, but never heard anything from the facility.

Record review on 11/18/14 of Patient #2's closed electronic medical record with Associate Chief Nursing Officer (CNO) #51 revealed the patient came to the ED (Emergency Department) on 9/8/14 at 5:55 p.m. with complaints of a headache.

Record review of Patient #2's History and Physical dated 8/22/14 revealed she was allergic to Tramadol, penicillin and iodine contrast.

Record review of Patient #2's Physician's Documentation dated 9/8/14 by Physician #58 at 6:40 p.m. revealed the differential diagnoses considered were migraine, neoplasm, post lumbar puncture headache, and tension headache. Physician #58 documented counseling with the patient a detailed discussion regarding the need for further work-up and treatment in the hospital.

Record review of Patient #2's Medication Record from the ED revealed the following:

Dilaudid 1 mg IV (intravenous) was given at 8:35 p.m. for pain.
Benadryl 25 mg and Compazine 10 mg were given IV at 11:07 a.m.

Record review of the patient's ED Intervention Record dated 9/8/14 at 11:03 p.m. revealed RN #61 gave report to RN #60 who worked on 5E where Patient #2 was to be admitted. The patient left the ED at 11:11 p.m.

Record review of Patient #2's Nurses' Note dated 9/8/14 (Monday) at 11:36 p.m. by RN #60 revealed the following:
"upon arrival on floor pt (patient) was sad and was not happy with ED (pt stated that ED nurses were not taking her seriously), so pt stated that she just wants to leave AMA and that she was not going to benefit from tonight stay here, MD notified, charge nurse notified, pt waiting on her husband to pick her up."

Phone interview on 11/19/14 at 8:28 a.m. with RN #60, he said Patient #2 told him she was not happy with her care in ED. She said the staff were not taking her seriously. She said they gave her medication she did not want. She said she was having a reaction to the medication that was making her feed "weird'. He said she was upset. RN #60 said he told her she was now on 5E with a new set of nurses and they would take good care of her. She said she was going to call her husband to come get her and leave AMA. He was asked what the policy was if a patient wanted to leave AMA. He said should notify the physician and the charge nurse. He said he called his charge nurse, RN #65, told her what was happening and he notified the physician.

Record review of Patient #2's AMA sheet revealed it was signed on 9/8/14 at 11:30 a.m.

Record review of the facility's Grievance Log for August through November, 2014 revealed no grievance report for Patient #2.

Interview on 11/19/14 at 8:40 a.m. with Associate CNO #51, she said AMA's who leave the ED department without being admitted are tracked and reported to the Emergency Medical Committee and Quality Assessment Performance Improvement staff attend that meeting. She said no report is generated for patients who leave AMA who have been admitted to the hospital.

During an interview on 11/19/14 at 8:50 a.m. with CNO (Chief Nursing Officer) #50, she was informed of Patient #2 leaving AMA after complaining to RN #60 that she had problems with her care in ED. She was informed no grievance report was generated. She said RN #60 should have initiated a grievance report. She said patient's who leave AMA are put in the PSN (Patient Safety Net) program in the computer, but that is not the same as a grievance response.

Patient #9

Record review on 11/19/14 of Patient #9's closed electronic medical record with Associate Chief Nursing Officer (CNO) #51 revealed the patient came to the ED (Emergency Department) on 11/7/14 at 7:20 p.m. with history of ulcerative colitis and gastrointestinal bleed. After being assessed and treated in the ED, the patient was admitted to ICU (Intensive Care Unit) bed 6 on 11/8/14 at 12 midnight.

Record review of the ICU Nurses' Notes dated 11/9/14 (Sunday) at 9:30 a.m. (entered in computer at 11:50 a.m.) by RN #69 revealed Patient #9's IV was infiltrated and needed to be replaced. The patient was refusing to let the nurse insert a new IV without the use of ultrasound. NP (Nurse Practitioner) #66 came to insert the IV with the use of an ultrasound machine, but the patient refused again. "pt talked about going home instead as he's not treated well in the hospital. " NP #66 tried to explain possible consequences of signing AMA, but the patient signed the form and left the unit at 11:40 a.m.

Interview on 11/19/14 at 11:30 a.m. with Associate CNO #51, she said a grievance report should have been initiated by what Patient #9 said when he left AMA.


Patient #11

Record review on 11/19/14 of Patient #11's closed electronic medical record with Associate Chief Nursing Officer (CNO) #51 revealed the patient came to the ED (Emergency Department) on 11/7/14 at 11:36 a.m. because of motor vehicle collision. He was complaining of chest pains for air bag contusions. He was admitted to 6E.

Record review of Patient #11's AMA sheet dated 11/11/14 at 12:15 a.m. revealed a hand written note as follows: "I left because I have been mis-dosed."

Interview on 11/19/14 at 11:10 a.m. with Associate Chief Nursing Officer (CNO) #51 and Director of Quality Management #52, they both agreed neither Patients #9 or #11 had grievance reports initiated and both should have had an investigation.

Record review of the facility's Policy and Procedure for Patients and Legally Authorized Representative (LAR) Grievance dated 4/30/14 revealed the following:
"I. POLICY/GENERAL STATEMENT
....Each hospital has established a process for prompt resolution of patient grievances or concerns and informs each patient whom to contact to file a grievance. Each hospital encourages employees to resolve and report patient concerns to hospital management....

II. DEFINITIONS
...Grievance: A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the LAR/companion regarding the patient's care, discrimination, abuse or neglect issues....

If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further actions for resolution, then the complaint is considered a grievance.

A written complaint is always considered a grievance whether from an inpatient, outpatient, released/discharged patient or his/her LAR/companion regarding care provided, abuse or neglect....An email or Fax is considered 'written'....

III. PROCEDURE
...C. Grievances or allegations of neglect or abuse will be investigated immediately.
D. Each department/unit director is accountable for investigating and assisting with resolving patient grievances related to their areas.

Interview on 11/19/14 at 11:45 a.m. with Quality Management Director #52, she said Patient Liaisons were responsible for the investigation of grievances. The Liaisons would channel the grievance to the appropriate managers and directors. They would make sure the grievance was investigated and they would contact the patient if they were still in-house. They were responsible for sending the appropriate letters. She said the Patient Liaisons worked Monday through Friday 8 a.m. to 5 p.m. She said there was one Patient Liaisons who worked in ED from 12 p.m. to 9 p.m. Monday through Friday.