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Based on record reviews and interviews, the hospital failed to ensure the health care services were furnished in accordance with appropriate written policies that were consistent with applicable State law as evidenced by:
1) Failing to report an allegation of abuse to HSS within 24 hours of knowledge of the allegation in accordance with hospital policy for 1 (#3) of 1 patient record reviewed with an allegation of abuse from a sample of 5 patient records and
2) Failing to implement its grievance policy related to provision of a resolution letter for 3 (#3, R1, R2) of 3 grievances reviewed for resolution from a sample of 5 patients and 2 random patients.
Findings:

1) Failing to report an allegation of abuse to HSS within 24 hours of knowledge of the allegation in accordance with hospital policy:
Review of the hospital policy titled "Abuse & Neglect Policy", presented as a current policy by S2CQO, revealed physical abuse was defined as the use of physical force that may result in bodily injury, physical pain, or impairment. Further review revealed the staff member along with the leadership member documents all information concerning the incident that occurred on hospital property on the Hospital Abuse/Neglect Initial Report. The report is to be submitted on hospital letterhead by fax to LDH within 24 hours of the knowledge of the allegation.

Review of a grievance received by S4AS on 12/06/17 revealed Patient #3's parent called to report that Patient #3 was seen in the ED on 12/04/17 for constipation. Further review revealed the parent reported that S6MD was the physician, and a male nurse assisted the physician in giving the child an enema. The parent indicated when the nurse moved the child into position to receive the enema, the child began to cry. Further review revealed the parent reported that when the enema was completed, the child's leg was limp, and they could not console the child. The parent of Patient #3 reported that after leaving the ED, they took Patient #3 to another ED from which the child was transferred and admitted to another hospital for treatment of a broken femur.

In an interview on 02/20/18 at 2:05 p.m. with S2CQO and S3CNO present, S2CQO confirmed she had not reported the parent's allegation of abuse of Patient #3 to HSS.

2) Failing to implement its grievance policy related to the provision of a resolution letter:
Review of the policy titled "Patient Complaint & Patient Grievance Resolution Process", presented as a current policy by S2CQO, revealed grievances will be acknowledged in writing. Following investigation a follow up letter will be sent within 15 working days of becoming aware of the grievance. In the event a grievance is not resolved promptly, the Director of Quality Resources will provide an update and inform the patient or the patient's representative that the hospital is still working to resolve the grievance will follow up with a written response as soon as possible and give an estimated number of days. The resolution of the grievance will be provided to the patient by written notice and will contain contact information of the Director of Quality and/or the Chief Executive Officer, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Review of a grievance received by S4AS on 12/06/17 revealed Patient #3's parent called to report that Patient #3 was seen in the ED on 12/04/17 for constipation. Further review revealed the parent reported that S6MD was the physician, and a male nurse assisted the physician in giving the child an enema. The parent indicated when the nurse moved the child into position to receive the enema, the child began to cry. Further review revealed the parent reported that when the enema was completed, the child's leg was limp, and they could not console the child. The parent of Patient #3 reported that after leaving the ED, they took Patient #3 to another ED from which the child was transferred and admitted to another hospital for treatment of a broken femur.

Review of a letter dated 12/26/17, written by S2CQO, and addressed to Patient #3's mother revealed the letter included that S2CQO and S3CNO worked closely with the ED staff and ED physicians to review the care provided for your child. Further review revealed the letter included that it is part of the hospital's policy to notify their Risk Management Company, and they have worked closely with the company representative to evaluate the care the hospital provided. There was no documented evidence that the letter contained the results of the grievance process, the date of completion, and/or that a follow-up letter would be sent at completion of the investigation with an estimated number of days given for the follow-up letter to be sent.

In an interview on 02/20/18 at 1:15 p.m., S2CQO indicated because this grievance became a claim, and the hospital didn't find the same things that were reported by Patient #3's father, she didn't put an outcome of the investigation in the resolution letter. She confirmed the letter did not include a completion date.

Patient R1
Review of a grievance received by S4AS on 01/09/18 and documented by S2CQO revealed Patient R1 called to report she was seen in the ED on 01/09/18. Further review revealed Patient R1 reported S6MD told her she (S6MD) wasn't giving her pain medication. After S4AS told Patient R1 the grievance process, the patient hung up. On 01/10/18 Patient R1 left a message with her name and number and stated S6MD walked in the room and stated "Don't come back to my hospital for damn pain medication ever again. You are now discharged." Further review of the grievance revealed the nurse present in the ED told S2CQO that S6MD examined Patient R1 and planned to discharge her. The nurse indicated S6MD told Patient R1 she would not write a prescription for pain medication, and Patient R1 left mad. The nurse told S2CQO that S6MD was not rude or unprofessional with the patient.

Review of the response letter sent 01/10/18 to Patient R1 by S2CQO indicated a written response will be provided to notify you of steps we've taken in response to your grievance. There was no time interval included in the letter of when the response would be sent. There was no documented evidence that a response letter was sent since 01/10/18.

In an interview on 02/21/18 at 1:25 p.m., S2CQO indicated she was waiting on the ED's Medical Director's response to his investigation, and he wants to have a discussion on the action to be taken. She confirmed she's waiting for the meeting before she sends the final response letter. S2CQO confirmed the grievance policy was not followed, because she did not include an estimation of the number of days in which the follow-up letter would be sent.

Patient R2
Review of the grievance received on 12/14/17 by S10CEO from Patient R2's fiance' revealed he reported Patient R2 came to the ED on 12/08/17 about 5:30 p.m. with complaints of leg pain, leg swelling, and was worried about a clot. Further review revealed Patient R2 had hip surgery 11/06/17 and was on Lovenox post-op until 11/29/17. Further review revealed Patient R2 also had a Factor 5 blood disorder. Patient R2's fiance' reported that an ultrasound was ordered and performed, and the ultrasound tech scanned behind the knee but not the lower calf. He reported the ED physician said the ultrasound results were alright and discharged the patient on muscle relaxants. Patient R2's fiance' reported that Patient R2 continued with pain and called her orthopedist who ordered a vascular ultrasound on 12/11/17 which showed a clot. Patient R2 was admitted to another acute care hospital with a computerized tomography showing a clot in the lung.

Review of the response letter dated 01/10/18, addressed to Patient R2, and sent by S2CQO (19 business days after knowledge of grievance) stated "I had hoped by this time to be able to provide you with a written response completing this investigation, however, it is requiring more investigation. I will provide a written response to notify you of further steps we have taken in response to your grievance.

There was no documented evidence of another response resolution sent to Patient R2 after 01/10/18 (30 business days since the original letter was sent).

In an interview on 02/21/18 at 1:30 p.m., S2CQO indicated she was waiting on the ED's Medical Director's response, and he wants them to have a discussion on the action to be taken. She confirmed she's waiting for the meeting before she sends the final response letter. S2CQO confirmed the grievance policy was not followed, because the initial response letter was not sent within 15 working days, and it did not include an estimation of the number of days in which the follow-up letter would be sent.

Based on record reviews and interviews, the hospital failed to ensure each patient's medical record contained reports of physical examinations as evidenced by failure to have documented evidence of S6MD's examination of Patient #3's left leg after the parent requested the nurse to report concerns to the physician for 1 (#3) of 5 sampled patient records reviewed for documentation of physician examinations from a sample of 5 patients.
Findings:

Review of Patient #3's medical record revealed she presented to the ED on 12/04/17 at 7:33 p.m. with a chief complaint of "crying child." Further review revealed S6MD documented that she had removed a fecal impaction manually on 12/04/17 at 7:52 p.m.

Review of Patient #3's medical record revealed S5RN's "Addenda/Correction(s)" documented on 12/05/17 at 7:43 p.m. revealed on 12/04/17 at 8:10 p.m. Patient #3's father asked her (S5RN) if S6MD could check Patient #3's left leg, because she was not moving it like she normally does. Further review revealed S5RN notified S6MD of the parent's concern of left leg pain.

Review of Patient #3's ED "Physician Medical Record" documented by S6MD revealed no documented evidence that S6MD had examined Patient #3's left leg after being informed by S5RN of the parent's concern.

In an interview on 02/20/18 at 2:40 p.m. with S6MD, S2CQO, and S3CNO present, S6MD indicated she examined Patient #3's legs after being told that the parent reported that "the leg was hurting." When informed by the surveyor that there was no documentation in the medical record that S6MD had examined the left leg, S6MD indicated she thought the leg that was reported hurting was the leg where the injection had been given (right leg). When asked why she didn't document her examination, S6MD answered "I don't know." After reviewing Patient #3's medical record, S6MD confirmed she had not documented an examination of Patient #3's legs when she went in the room for a third time after the nurse had reported the parent's concern to her.

Based on record reviews and interview, the hospital failed to ensure each patient's medical record contained progress notes describing the patient's response to treatment as evidenced by failure of S5RN to document the response to medication administered for a diagnosis of Constipation for 1 (#5) of 5 sampled patient records reviewed for documentation of response to treatment from a sample of 5 patient records.
Findings:

Review of Patient #5's medical record revealed she was a 21 month female presenting to the ED on 01/03/18 at 3:56 a.m. with a chief complaint of constipation.

Review of Patient #5's ED "Physician Medical Record" documented by S9MD revealed S9MD ordered a Glycerin Pediatric Suppository to be inserted rectally on 01/03/18 at 4:08 a.m. for a diagnosis of Constipation.

Review of Patient #5's ED "Nursing Medical Record" revealed S8RN administered a Glycerin Pediatric Suppository rectally on 01/03/18 at 4:08 a.m.

Review of Patient #5's medical record revealed S5RN documented that Patient #5 was discharged home on 01/03/18 at 4:42 a.m. There was no documented evidence of an assessment for the effectiveness of and response to the Glycerin Pediatric Suppository prior to Patient #5 being discharged.

In an interview on 02/21/18 at 8:00 a.m., S5RN indicated doctor doesn't usually discharge patients from the ED "unless they go" (meaning unless the patient has had a bowel movement after receiving treatment). She further indicated if she sees the bowel movement, she would document it, but she didn't remember if Patient #5 had a bowel movement. S5RN confirmed she should have documented an assessment of the effectiveness of the medication that was administered to Patient #5 prior to discharging her.