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.

HEART HOSPITAL OF LAFAYETTE 1105 KALISTE SALOOM ROAD LAFAYETTE, LA 70508 Aug. 26, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, the hospital, in its resolution of a grievance, failed to provide written notice of its decision that contains the results of the grievance process and the date of completion. Deficiencies were noted for 3 of 4 grievances (#1, #2, #3) reviewed out of a total sample of 6 patients. Findings:

The hospital's policy/procedure titled "Patient/Family/Visitor Complaint and Grievance Resolution" was reviewed. The policy/procedure documents the process for informing patients and visitors whom to contact if they wish to file a grievance and for receiving and reviewing concerns, complaints, and/or grievances. The policy/procedure documents "Management attempts to resolve grievances as soon as possible. Management reviews/investigates/analyzes each grievance in order to determine the most appropriate resolution within the following time frame guidelines: 1. Grievances about situations that endanger the patient, such as neglect or abuse, are reviewed immediately given the seriousness of the allegation and the potential for harm to the patient(s). 2. The resolution to most grievances is reached within 7 days as practicable, and a written response is generated to the patient or patient's representative. 3. If the grievance will not be resolved within 7 days or if the investigation will not be completed within 7 days, the hospital informs the patient or the patient's representative that the hospital is still working to resolve the grievance and the anticipated timeframe in which the patient/patient representative can expect a written response. 4. Management attempts to resolve grievances within 30 days. Exceptions are those occasional grievances that require extensive investigation, review and/or input from multiple individuals or additional effort due to more complicated facts and circumstances." The policy/procedure further documents "A written explanation of hospital's determination regarding the grievance is communicated to the patient or the patient's representative in a language and manner that is understandable to the patient and/or patient representative. The hospital will respect the patient's privacy and confidential information throughout the process in accordance with all HIPPA regulations. The hospital may use tools to resolve grievances such as meeting with the patient and/or patient's representative, or other methods it finds effective. However, in such cases the hospital will provide a written response to the patient's grievance that includes the following: 1. Name of the hospital contact person. 2. Steps taken to investigate the grievance. 3. Results of the grievance process. 4. Date of completion."

Patient #1:
Review of the grievance log revealed a grievance was reported for Patient #1 on 7/12/11.

The Medical Record of Patient #1 was reviewed. This review revealed Patient #1 presented to the hospital's ED (Emergency Department) on 6/25/11 at 9:20 p.m. and was discharged on [DATE] at 12:50 a.m.

Review of the "Risk Management Worksheet" dated 8/24/11 revealed no documented evidence Patient #1 was mailed a letter as per policy.

The Performance Improvement Director (S3) was interviewed on 8/25/11 at 12:40 p.m. and at 12:45 p.m. regarding the grievance filed by Patient #1. He indicated the patient's (#1's) daughter called complaining that the patient was seen and treated in the Emergency Department (ED) for severe back pain. The patient was administered two (2) injections of pain medication. The patient's pain was controlled while lying still but when she tried to move she was in extreme pain. The patient's mother died of an abdominal aortic aneurysm, so the physician ruled it out by performing an ultrasound of the abdominal aortic. The physician discharged the patient back to the living center and the patient was told to follow-up with her private doctor. The patient was admitted to a local hospital within 4 days of being discharged from the ED and was diagnosed with [DIAGNOSES REDACTED]#1's representative was not mailed a written notice of the hospital's decision that contains the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion as per policy.

Patient #2:
Review of the grievance log revealed a grievance was reported by Patient # 2 on 5/16/11.

The Medical Record of Patient #2 was reviewed. Documentation revealed Patient #2 presented to the hospital's ED (Emergency Department) on 5/12/11 at 4:48 p.m. and was discharged on [DATE] at 7:01 p.m.

S1 (Director of Nursing) and S3 (Performance Improvement Director) were interviewed on 8/25/11 at 9:10 a.m. regarding the grievance filed by Patient #2.

S1 reported she received a phone call on 5/16/11 from Patient #2. S1 reported Patient #2 was upset during the phone call and was reporting that she did not feel like she had been properly treated during her visit to the hospital's emergency room on [DATE]. S1 reported she was with S3 at the time of receiving the phone call and placed Patient #2 on speaker phone so that her (S1) and S3 could hear Patient #2's complaint. S1 indicated Patient #2 said the ED physician (S5) and the night nurse (S4) were rude and minimized her concerns.

S3 indicated that he is responsible for the implementation of the hospital's grievance process. S3 reported that a letter was mailed to Patient #2 on 6/06/11 to the address documented in Patient #2's medical record. S3 reported Patient #2 called and spoke with S1 on 8/05/11 and informed her (S1) that she (Patient #2) never received any follow up from her complaint. S3 indicated he called Patient #2 back and apologized for her not receiving the letter dated 6/06/11. S3 reported Patient #2's address in the medical record was not correct as the address showed Patient #2 living in one town when she actually lives in another. S3 indicated that he informed Patient #2 he was resending the letter explaining what was done as a result of her complaint.

The letter mailed to Patient #2 on 6/06/11 was reviewed. The letter was dated 6/06/11 and documents "This is a follow up letter to our second telephone conversation regarding the care you received in our Emergency Department by (S5). Like I mentioned in our conversation, I have brought your concerns about (S5) to the medical director of emergency department and he will follow up with (S5). (S1) the director of nursing has spoken to the nurses involved and discussed the concerns you had about the discharging nurse. Creating a positive experience for our patients/customers is vitally important to us and we regret that your experience did not meet your expectations. Please be assured your input is taken very seriously and has helped us in reviewing our processes for delivery of care. We sincerely appreciate the opportunity to receive feedback and address any matter that can improve how we respond to our customers. Again, thank you for taking the time to contact us about the issue you reported".

When asked if the hospital maintained a receipt to indicate the letter was mailed on 6/06/11 to the address documented in Patient #2's medical record, S3 reported there was no documentation to indicate the letter was mailed to Patient #2 on 6/06/11.

The letter mailed to Patient #2 on 8/05/11 was reviewed. The letter was dated 8/05/112 and documents "This is a follow up letter to our second telephone conversation regarding the care you received in our Emergency Department by (S5). Like I mentioned in our conversation, I have brought your concerns about (S5) to the medical director of emergency department and he will follow up with (S5). (S1) the director of nursing has spoken to the nurses involved and discussed the concerns you had about the discharging nurse. Creating a positive experience for our patients/customers is vitally important to us and we regret that your experience did not meet your expectations. Please be assured your input is taken very seriously and has helped us in reviewing our processes for delivery of care. We sincerely appreciate the opportunity to receive feedback and address any matter that can improve how we respond to our customers. Again, thank you for taking the time to contact us about the issue you reported".

In an interview on 8/26/11 at 9:40 a.m., S3 (Performance Improvement Director) confirmed the written notification provided to Patient #2 did not include the results of the grievance process or the date of completion. S3 reported the letter that was sent to Patient #2 indicated that follow up was still needed in regards to the medical director of the emergency department and S5.

Patient #3:
Review of the grievance log revealed a grievance was reported by Patient #3's spouse on 3/9/11.

The medical record for Patient #3 was reviewed and revealed the patient was admitted on [DATE] at 2:15 p.m. with an admitting diagnosis of [DIAGNOSES REDACTED]

The letter mailed to Patient #3 on 3/11/11 was reviewed. The letter was dated 3/11/11 and documents " ...would like to thank you for bring the concerns about nursing not being aware of patient's allergies to medication and not checking blood sugar before discharging home to our attention. I have discussed your concerns with the director of nursing for patient care unit. She is going to discuss your concerns at next staff meeting. We sincerely appreciate the opportunity to receive feedback and address any matter that can improve how we respond to our customers. Again, thank you for taking the time to contact us about the issues you reported ... ".

S3 was interviewed on 8/25/11 at 11:15 a.m. and on 8/26/11 at 9:30 a.m. regarding the grievance filed for Patient #3 on 3/9/11. S3 indicated Patient #3's spouse had two (2) concerns with the first being that the nurse gave Patient #1 Lortab for pain when the nurse was told the patient could not take any codeine products because it made her feel like she was coming out of her skin and the second being that the nurse did not check her blood sugar before being discharged and when the patient arrived home later that evening her blood sugar was 498 on her home glucose monitor. S3 confirmed the written notification provided to Patient #3's spouse did not include the results of the grievance process or the date of completion.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, the hospital, in its resolution of a grievance, failed to ensure the effective operation of the grievance process by failing to conduct a thorough investigation of the grievance that included documented investigatory findings of steps taken by the hospital to resolve the grievance. Deficiencies were noted for 4 of 4 grievances (#1, #2, #3, #4) reviewed out of a total sample of 6 patients. Findings:

Patient #1:
Review of the grievance log revealed a grievance was reported for Patient #1 on 7/12/11.

The Medical Record of Patient #1 was reviewed. This review revealed Patient #1 presented to the hospital's ED (Emergency Department) on 6/25/11 at 9:20 p.m.

The Performance Improvement Director (S3) was interviewed on 8/25/11 at 12:40 p.m. and at 12:45 p.m. regarding the grievance filed on behalf of Patient #1. S3 indicated Patient #1's daughter called complaining about the services provided during Patient #1's visit to the hospital's Emergency Department indicating that the treatment provided to Patient #1 was not adequate. S3 reported that an investigation was conducted by the hospital. When asked to provide documentation relating to the findings of the investigation that would include all steps taken by the hospital to thoroughly investigate the grievance, S3 indicated that he did not have any documented evidence of what was done to investigate the allegations alleged by the daughter of Patient #1.

Patient #2:
Review of the grievance log revealed a grievance was reported by Patient # 2 on 5/16/11.

The Medical Record of Patient #2 was reviewed. Documentation revealed Patient #2 presented to the hospital's ED (Emergency Department) on 5/12/11 at 4:48 p.m. and was discharged on [DATE] at 7:01 p.m.

S1 (Director of Nursing) and S3 (Performance Improvement Director) were interviewed on 8/25/11 at 9:10 a.m. regarding the grievance filed by Patient #2.

S1 reported she received a phone call on 5/16/11 from Patient #2. S1 reported Patient #2 was upset during the phone call and was reporting that she did not feel like she had been properly treated during her visit to the hospital's emergency room on [DATE]. S1 reported she was with S3 at the time of receiving the phone call and placed Patient #2 on speaker phone so that her (S1) and S3 could hear Patient #2's complaint. S1 reported Patient #2 said the ED physician (S5) and the night nurse (S4) were rude and minimized her concerns. S1 reported she spoke with S5 (no documentation of this meeting recorded) and he (S5) indicated that Patient #2 had presented to the ED with complaints of Headache and numbness. S1 reported S5 indicated there were inconsistencies with Patient #2's complaints as the clinical examination findings did not match what she (Patient #2) was reporting. S1 reported S5 indicated that he performed a medical screening examination and stabilizing treatment for Patient #2 while in the ED and Patient #2 was told to follow up with her primary physician. S1 reported S5 indicated that he did not feel Patient #2 had a medical emergency and she (Patient #2) got upset after finding out that he (S5) was not going to prescribe any narcotics for her. S1 reported she spoke with S2 (Registered Nurse) within the next couple of days (no documentation of this meeting recorded) and S2 informed her that Patient #2 was upset because she felt S5 was rude to her and failed to appropriately treat her. S1 reported that S2 indicated S5 was "direct and matter of fact" with Patient #2 after she (Patient #2) got upset about the prescriptions. S1 reported that S2 indicated that she felt the treatment provided to Patient #2 was appropriate. S1 reported she contacted S6 (South Central Regional Medical Officer and Director for the contracted service provider for ED physicians) on 5/16/11 to inform him of Patient #2's complaint against S5. S1 reported that S6 informed her that he (S6) would look into it. When asked if she had received any feedback from S6 relating to his investigatory findings, S1 reported that she did not receive any feedback from S6 relating to his (S6) investigatory findings. When asked if she maintained any documentation of the investigatory findings from her interviews that would include the dates and times of her interviews and the information obtained in the interviews, S1 reported that she did not record any information obtained in the interviews.

In an interview on 8/26/11 at 9:40 a.m., S3 indicated that he is responsible for the implementation of the hospital's grievance process. S3 (Performance Improvement Director) reported that he was unable to provide any documentation relating specifically to the investigatory findings of the grievance filed by Patient #2.

Patient #3:
Review of the grievance log revealed a grievance was reported by Patient #3's spouse on 3/9/11.

The medical record for Patient #3 was reviewed and revealed the patient was admitted on [DATE] at 2:15 p.m. with an admitting diagnosis of continuous cardiac monitoring and was discharged on [DATE] at 1:30 p.m.

S3 (Performance Improvement Director) was interviewed on 8/25/11 at 11:15 a.m. and on 8/26/11 at 9:30 a.m. regarding the grievance filed on behalf of Patient #3 on 3/9/11. S3 indicated Patient #3's spouse had two (2) concerns with the first being a nurse gave the patient Lortab for pain after a nurse was told the patient could not take any codeine products because it made her feel like she was coming out of her skin and the second being the nurse did not check the patient's blood sugar on the day of discharge and the patient's blood glucose level was 498 when she arrived home. S3 verified the admission orders had documented Patient #3 had a codeine allergy and was to be administered Lortab pain medication. S3 indicated he did not have any documented evidence of what he reviewed in the medical record to investigate the allegations made by Patient #3's spouse and did not have documentation of any staff interviews conducted during the investigation of this grievance.

In an interview conducted on 8/26/11 at 8:35 a.m., S1 (Director of Nursing) indicated that she investigated the grievance filed for Patient #3. S1 stated she did not have documented evidence of an investigation being conducted regarding Patient #3's codeine allergy. In addition, S1 indicated that the written response to Patient #3's grievance was mailed 3/11/11 prior to the interview conducted with S10RN which was on 3/12/11. S1 indicated the investigation was not complete prior to providing Patient #3's representative a written letter.


Patient #4:
Review of the grievance log revealed a grievance was reported by Patient #4's spouse on 7/25/11.

The medical record for Patient #4 was reviewed and revealed the patient was admitted on [DATE] at 11:15 p.m. with an admitting diagnosis of syncope, Bradycardia and observation. Further review revealed Patient #4 was discharged on [DATE] at 12:00 p.m.

In an interview conducted on 8/25/11 at 1:05 p.m., S3 (Performance Improvement Director) indicated that he had spoken to Patient #4's spouse regarding his complaints which included no food or fluids for over 13 hours after arriving at the hospital with no orders for food or fluids, ants in the bathroom and in the sofa she had to sleep on, told the PCP who just laughed and walked out, PCP took blood pressure over the IV site, PCP missed the trash can when throwing away the temperature probe, and finally got a tray of food that looked like it was "2 weeks old" and the bread was hard. S3 indicated that he did not have documentation of any staff interviews or record reviews conducted during the investigation of this grievance.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to identify a breakdown in the effective implementation of the grievance process and failed to ensure the development and implementation of quality indicators relating to this breakdown. This was evidenced by the hospital's failure to identify, in its resolution of grievances, the need to conduct a thorough investigation that includes documented investigatory findings and the need to include a written response that includes all required components. Findings:

The hospital's complaint/grievance records relating to Patient #1, Patient #2, and Patient #3 were reviewed. This review revealed no evidence to indicate that the hospital maintained documented evidence of investigatory findings relating to the hospital's internal investigation. In addition, this review revealed no evidence to indicate that the hospital provided a written response to the grievance that included the results of the investigation of the grievance and/or the date of completion.

The hospital's QAPI (Quality Assurance Performance Improvement) data was reviewed. This review revealed no evidence to indicate the hospital had identified a breakdown in the implementation of the grievance process.

S3 (Performance Improvement Director) was interviewed on 8/26/11 at 9:40 a.m. S3 confirmed the hospital failed to identify the breakdown in the effective implementation of the grievance process. S3 confirmed there were no quality indicators developed and monitored relating to this breakdown.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to identify a breakdown in the effective implementation of the grievance process and failed to ensure the development and implementation of quality indicators relating to this breakdown. This was evidenced by the hospital's failure to identify, in its resolution of grievances, the need to conduct a thorough investigation that includes documented investigatory findings and the need to include a written response that includes all required components. Findings:

The hospital's complaint/grievance records relating to Patient #1, Patient #2, and Patient #3 were reviewed. This review revealed no evidence to indicate that the hospital maintained documented evidence of investigatory findings relating to the hospital's internal investigation. In addition, this review revealed no evidence to indicate that the hospital provided a written response to the grievance that included the results of the investigation of the grievance and/or the date of completion.

The hospital's QAPI (Quality Assurance Performance Improvement) data was reviewed. This review revealed no evidence to indicate the hospital had identified a breakdown in the implementation of the grievance process.

S3 (Performance Improvement Director) was interviewed on 8/26/11 at 9:40 a.m. S3 confirmed the hospital failed to identify the breakdown in the effective implementation of the grievance process. S3 confirmed there were no quality indicators developed and monitored relating to this breakdown.