The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LUTHERAN MEDICAL CENTER 8300 W 38TH AVE WHEAT RIDGE, CO 80033 June 29, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and document review, the facility failed to ensure grievances were investigated according to policy.

This failure created grievances to go unresolved by the facility and allowed for deviation from the process approved by the facility's governing body for grievance investigation and resolution.

FINDINGS

POLICY

According to Patient Complaints and Grievances Process Policy, the Patient Advocate will investigate grievances with staff, SCC, CM, etc. The Patient Advocate sends a final written response letter within 7 working days or 15 working days if additional investigation is needed.

1. The facility failed to ensure Patient #1's grievance was investigated and resolved.

a) A review of Patient #1's medical record revealed s/he arrived confused to the Emergency Department on 04/20/16 at 4:55 for intoxication and post a fall. At 8:04 p.m., the patient required 4 point leather restraints due to agitation and combativeness. At 8:56 p.m. staff cut Patient #1's clothes off upon arrival into the Behavioral Health Care area in the Emergency Department.

b) Review of the grievance documentation, dated 05/05/16, revealed Patient #1 felt violated, abused and handled roughly during his/her Emergency Department (ED) visit on 04/20/16.

A review of the Multiple Issues Feedback (a running report of all correspondence related to the specific grievance), dated 05/06/16, revealed Patient Advocate (PA) #1 informed Emergency Department (ED) Clinical Co-Manager #2, ED Physician #4 and Clinical Manager #5 of Patient #1's patient care concerns.

A summary of a conversation between Patient #1 and PA #1 was emailed to Clinical Manager #3 on 05/25/16 at 7:24 a.m., which detailed Patient #1's care concerns and lack of communication from the ED.

However, during an interview with Clinical Manager #3, on 06/29/16 at 11:58 a.m., s/he stated s/he was unaware of Patient #1's patient care concerns but was aware of the patient's claim of missing earrings.

c) During an interview, on 06/29/16 at 1:01 p.m., ED Clinical Co-Manager #2 stated Emergency Department Nurse Manager #5 had been responsible for the grievance investigation and updating Patient #1 of the findings. Additionally, s/he stated Emergency Department Nurse Manager #5 had left the facility shortly after the grievance had been filed without any documentation of the investigation.

d) An interview with Director of Quality (Director) # 6 was conducted on 06/29/16 at 1:31 p.m. Director #6 stated s/he was trying to determine if Patient #1's alleged abuse case had been investigated. Director #6 stated Clinical Manager #5 (who was no longer employed by the facility) had the responsibility of investigating the grievance by interviewing staff involved, reviewing the documentation in the electronic medical record and video review, all of which had not been completed. Director #6 stated the grievance should not have been closed until the full investigation had been completed.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and document review, the facility failed to ensure resolution of grievances were complete and the patient notified within the specified time frame in 1 of 4 closed grievance files (Patient #1).

This failure created the potential that patient's would be unaware of the outcome of the grievance and their right to appeal the facility investigation.

FINDINGS

POLICY

According to Patient Complaints and Grievances Process Policy, the facility will send a final written response to patient or patient's representative within seven (7) working days of submittal of the grievance. In the event the grievance is complicated and requires extensive investigation and analysis, the person responsible for the response to the patient will send a written interim response within seven (7) working days stating that the hospital is still working on the response which they should expect within 15 working days total from original submittal of the grievance.

The final written response will include the following information in a language and manner the patient or the patient's representative understands:

The name of the hospital contact person
Steps taken on behalf of the patient to investigate the grievance
Results of the grievance process, not to include any information which is considered legally protected information
Date of completion

1. The facility failed to ensure Patient #1 received a written letter which detailed the investigation and resolution of his/her grievance.

a) A review of Patient #1's medical record revealed s/he arrived confused to the Emergency Department on 04/20/16 at 4:55 for intoxication and post a fall. At 8:04 p.m., the patient required 4 point leather restraints due to agitation and combativeness. At 8:56 p.m., staff cut Patient #1's clothes off upon arrival into the Behavioral Health Care area in the Emergency Department.

b) On 05/05/16 Patient #1 submitted a grievance pertaining to patient care in the Emergency Department. There was no resolution letter to show the complainant had been notified of the outcome of the investigation.

c) An interview with Patient Advocate (PA) #1 and Director of Quality #6 was conducted on 06/29/16 at 11:00 a.m. Patient Advocate #1 stated a copy of the resolution letter would have been located in the Multiple Issues Feedback Report (an ongoing documentation of all communication between facility and patient).

Patient Advocate #1 and Director #6 stated Patient #1's grievance had been closed and a letter of resolution should have been sent out at that time according to policy.