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.

CATAWBA VALLEY MEDICAL CENTER 810 FAIRGROVE CHURCH RD HICKORY, NC 28602 March 4, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, patient grievance case review and staff interview, the facility failed to provide a written notice of the hospital's determination regarding the patient's grievance communicated to the facility for 1 of 1 sampled medical records that contained a grievance case (Patient #2).

Findings included:

Review on 03/04/2015 of the facility's policy and procedure "Complaint/Grievance Policy and Patient Advocacy" (approval date 04/09/2014) revealed "6. Director, Department Manager or higher level of management provides a written response to the patient within seven (7) days of receiving the complaint. The written response should include: 7. Name of hospital contact person. 8. Steps taken to investigate. 9. Results of the investigation. 10. Date of Completion."

Closed medical record review on 03/04/3015 for patient #2 revealed the patient presented to the hospital's ED (Emergency Department) on 04/08/2014 for complaint of "Abdominal Pain and Nausea/Vomiting." The documentation of the patient's medical record revealed she was treated and discharged on [DATE] with a same day follow up to another hospital and her surgeon for further care and evaluation.

Review on 03/04/2015 revealed the facility's administration presented a grievance case for patient #2 that included concerns from the patient related to her care and treatment while at the hospital's ED on 04/08/2014-04/09/2014. Review of the grievance revealed the patient reported her concerns to the ED Department Director related to ED physician care while at the hospital. A letter from the ED Department Director was sent to the patient on 04/28/2014 (longer than 7 days) that indicated he was forwarded her concerns to the ED Medical Director for follow up of her concerns. The review revealed the Department Director forwarded the information to the ED Medical Director who investigated the allegations. The review revealed the ED Medical Director made a telephone call to the patient on 04/29/2014 related to her grievance concerns. Review of a second facility letter sent to the patient dated 08/14/2014 from a hospital Vice President revealed in the letter an apology to the patient for "it taking so long for someone at the hospital to call her back." The review revealed revealed that no written notice of the determination regarding the patient's grievance was sent to the patient.

Interview on 03/04/2015 at 1135 via telephone with patient #2 revealed that she did file a complaint about her care and treatment to the hospital's ED Department Director immediately after her care and treatment on 04/09/2014. The interview also revealed that no one would call her back and she had to keep calling in order for her concerns to be addressed. The interview did confirm the hospital's administration finally called her back and followed up with her.

Interview on 03/04/2015 at 1125 with the hospital's vice president revealed that she could not remember much about the details of the patient's grievance. The interview did reveal she sent a letter to the patient on 08/14/2014 after the patient had previous concerns on 04/09/2014 while in the ED about her care and wait times. The interview revealed that the hospital's vice president wished she could have remembered more and took more notes. The interview did confirm that there was no written resolution or response to the patient's grievance filed from her 04/08/2014-04/09/2014 care and treatment in the hospital's ED.