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Based upon hospital policy and procedure review, grievance record reviews, staff interviews and medical record reviews, the facility staff failed to identify and investigate a grievance and provide a written letter of resolution to a complainant for 1 of 1 patient complaint (Patient #3).

The findings include:

Review on 02/11/2014 of the hospital's policy and procedure "Complaint/Grievance Process" last revised date of 11/2013 revealed "...A 'patient grievance' is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care ...Types of complaints/grievances: If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for alter resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance ...Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care ...ALL verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS (Centers for Medicare & Medicaid Services) requirements, are to be considered a grievance for the purposes of these requirements ...IV. Guidelines: ...2. When there is a patient grievance, the concern is: documented on an event report in the electronic event reporting system. Once submitted the Event Report will be routed to the department director for investigation and follow-up documentation as needed. The Risk Manager will receive a copy of the occurrence also. Patient grievances require written response to the patient/patient representative with seven (7) days ...Patient/patient representative meetings and/or telephone conferences may be used to resolve a grievance, however, a written response must be sent to the patient/patient representative within seven days ..."

Closed medical record review on 02/11/2014 revealed an eleven year old female, Patient #3, admitted on [DATE] for outpatient surgical procedure Right Knee Arthroscopy under general anesthesia. Record review revealed the patient was discharged on [DATE] at 1030.

Interview on 02/11/2014 at 1554 with the OR Nursing Director revealed "I started the case as the circulator. I did the time out and checked the consent then another RN (name of RN) took over as circulator. I have no memory of a conversation prior to the start of the procedure with the patient's parents. A couple of weeks after the patient was discharged I received a transfer telephone call from (name) our Risk Manager who informed me the patient's Mom had called requesting information about her daughter's surgery. I think it was about the length of surgery, but I'm not sure exactly because I can't recall the conversation. I couldn't answer her questions about the surgery so I had Dr. (name of patient's surgeon) (Physician #1) to call her. I don't remember a complaint, she was pleasant not angry...she was unclear about what had happened in the OR during her daughter's surgery and had questions. She had concern about her daughter's oxygenation and why the machine was not working properly. She was concerned about something Dr. (name of surgeon) (Physician #1) had told her about the anesthesia machine not working properly but I can't remember what it was she wanted to know...No grievance was filed because I didn't think she was filing a grievance. Yes, after we've talked about it I guess she was concerned about the quality of patient care with her daughter during the surgery. I don't know if any follow up has been done with the patient's mother. I don't know if Dr. (name of surgeon) (Physician #1) spoke to her after I asked him to. No, I didn't follow up with him ...I don't know if anyone has followed up with the mother regarding her concerns. I think this mother called twice asking questions about what occurred in the OR while her daughter was there but I only spoke with her once ...I don't know if her concerns were satisfactorily addressed." Interview confirmed the facility staff failed to identify a grievance and provide a written letter of resolution to a complainant.

Interview on 02/11/2014 at 1615 with the Risk Manager revealed "If a patient or family member calls to make a complaint or grievance it is filed in the data base. I do not have a complaint or grievance on file for this patient (#3). A grievance is anytime a patient calls or sends a letter or verbal complaint that can't be resolved at the moment while the patient is still here. When this patient's mother called she said her daughter had been a patient at our facility and had surgery. She said something happened during the procedure and she wanted someone to explain to her what happened during the procedure. She said after the procedure (name of surgeon) (Physician #1) came out and told her surgery was going to be delayed because her daughter was having a breathing problem. And they were going to have to do an x-ray and that he would come out with an update. He did come back out and told her the problem wasn't with her daughter...I guess it could have been a quality of care issue since she said there was something wrong her mind something went wrong with her daughter's surgery. I referred her to the OR director because I couldn't answer her questions. I don't know what follow up, if any was done...I did not follow up with the patient's mother to see if her issues or concerns had been resolved. I did not file this as a grievance therefore no resolution letter was mailed." Interview confirmed the facility staff failed to identify and investigate a grievance and provide a written letter of resolution to a complainant.

NC 689