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.

ST. MARY'S HEALTH, INC. 3700 WASHINGTON AVE EVANSVILLE, IN 47750 Nov. 13, 2013
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on document review and staff interview, the facility failed to follow policy related to discharge instructions for 1 of 6 patients (patient #6).

Findings include:

1. Facility policy titled "DISCHARGE OF EMERGENCY DEPARTMENT PATIENT" last reviewed/revised 9/18/13 states under policy statement on page 1: "All patients who are being discharged for the Emergency Department will receive printed condition appropriate instructions for home care and appropriate referrals."

2. Review of patient #1 medical record indicated the following:
(A) The patient presented to the emergency department (ED) at 6:20 a.m. on 6/13/13.
(B) A problem was identified with the discharge instructions. The discharge instructions sent with the patient was for abdominal pain. There was nothing in the medical record that indicated the patient had abdominal pain.

3. Staff member #3 indicated the following in interview beginning at 2:00 p.m. on 11/13/13:
(A) He/she verified that patient #1 received discharge instructions for abdominal pain and there was no indication that the patient had abdominal pain.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on document review and interview, the facility failed to review and resolve grievances for 1 of 6 patients (patient #6).

Findings include:

1. Document titled "Patient Complaint Follow-up Log" indicated that FM #1 of patient #1 phoned the facility and left several voicemails on 6/14/13 with a complaint concerning the care provided to patient #1. The document stated "I offered my apologies to (FM #1) advising I would be following up with the (FM #2) of the patient." On the same date (6/14/13), staff member #A1 spoke with FM #2 of patient #1 who voiced concerns with the care provided to patient #1." The document indicated that response/call to complainant was requested by both parties. The priority for timeliness of immediate response was listed as high. The document indicated that a review by the quality director was requested by the medical director. The complaint was forwarded to the quality director on 6/14/13. There was no resolution to the complaint. The section for quality review was left blank and there was no indication that the complainant was contacted as requested .

2. Facility policy titled "PATIENT COMPLAINT MANAGEMENT/GRIEVANCE PROCESS" last reviewed/revised 9/23/11 states on page 1: "Grievance- A formal or informal written or verbal complaint that is made to the Hospital by a patient, or the patient's representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present....." Under response on page 3, the policy states: "1. ....If not resolved, the staff member refers the concerns to the appropriate Department Director or Patient Relations for follow up. Responses will vary with the nature of the complaint, but are to be made on a timely basis. If investigation is required, ongoing contact with the complaining party is to be maintained during the time needed to complete the investigation/resolution........" Page 5 states "6. The grievance, including review, investigation, and resolution, is to be completed within seven (7) business day. However, based upon the complexity of the grievance and accompanying systemic issues, the Grievance Committee, with representation from the affected area, may approve an extension of this timeframe. 7. If the grievance will not be resolved......within seven (7) business days, the hospital will contact the patient or the patient's representative indicating a review is in process and that the hospital will follow-up with a written response within a stated number of days. 8. A follow-up letter is provided to the patient or his/her representative..............." 9. A grievance is considered resolved when the patient or his/her representative is satisfied with the actions taken on his/her behalf. E. Documentation regarding the grievance, maintained by Patient Relations or Risk Management, is to include:........"

3. Staff member #3 indicated the following in interview beginning at 2:00 p.m. on 11/13/13:
(A) Staff member #A1 had received a complaint from a family member of patient #1 concerning the care he/she received by M.D. #1.
(B) Contracted service #1 (contracted service for E.D. physicians) are in charge of complaints related to the E.D. physicians.
(C) After speaking with the Vice President of contracted service #1, he/she indicated that the service has no policy for patient grievances/complaints. They follow the facility policy.
(D) He/she verified that the complaint from the family of patient #1 had no follow-up from QA and no update to the complainant.

4. M.D. #2 (Medical Director for contracted service #1) indicated the following in phone interview beginning at 2:55 p.m. on 11/13/13:
(A) The form titled "Patient Complaint Follow-up Log" was developed by him/her for the facility and is used to direct information to the appropriate parties.
(B) He/she discusses the complaint with both the provider and the complainant.
(C) Complaints are handled through contracted service #1.

5. Staff member #1 indicated in interview at 3:05 p.m. on 11/13/13 that the patient relations department at facility #1 had no record of a complaint made by the family of patient #1.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and staff interview, the facility failed to provide the patient or patient representative with a written notice of the outcome of a patient grievance for 1 of 6 patients (patient #1).

Findings include:

1. Document titled "Patient Complaint Follow-up Log" indicated that FM #1 of patient #1 phoned the facility and left several voicemails on 6/14/13 with a complaint concerning the care provided to patient #1. The document stated "I offered my apologies to (FM #1) advising I would be following up with the (FM #2) of the patient." On the same date (6/14/13), staff member #A1 spoke with FM #2 of patient #1 who voiced concerns with the care provided to patient #1" The document indicated that response/call to complainant was requested by both parties. The priority for timeliness of immediate response was listed as high. The document indicated that a review by the quality director was requested by the medical director. The complaint was forwarded to the quality director on 6/14/13. There was no resolution to the complaint. The section for quality review was left blank and there was no indication that the complainant was contacted as requested.

2. Facility policy titled "PATIENT COMPLAINT MANAGEMENT/GRIEVANCE PROCESS" last reviewed/revised 9/23/11 states on page 5 "7. If the grievance will not be resolved......within seven (7) business days, the hospital will contact the patient or the patient's representative indicating a review is in process and that the hospital will follow-up with a written response within a stated number of days. 8. A follow-up letter is provided to the patient or his/her representative..............."

3. Staff member #3 indicated the following in interview beginning at 2:00 p.m. on 11/13/13:
(A) Staff member #A1 had received a complaint from a family member of patient #1 concerning the care he/she received by M.D. #1.
(B) The contracted physician group follows the facility grievance/complaint policy.
(C) He/she verified that the complaint from the family of patient #1 had no follow-up from QA and no update to the complainant.

3. M.D. #2 (Medical Director for contracted service #1) indicated the following in phone interview beginning at 2:55 p.m. on 11/13/13:
(A) The form titled "Patient Complaint Follow-up Log" was developed by him/her for the facility and is used to direct information to the appropriate parties.
(B) He/she discusses the complaint with both the provider and the complainant.

4 Staff member #1 indicated in interview at 3:05 p.m. on 11/13/13 that the patient relations department at facility #1 had no record of a complaint made by the family of patient #1.