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Based on hospital policy and procedure review, medical record review, grievance log review and staff interviews facility staff failed to identify a patient representatives concerns as a grievance and respond per hospital policy for 1 of 1 patients with documented patient care concerns in the medical record. (#2)

The findings include:

Review on 08/15/2017 of a policy titled "Patient Complaint and Grievance Response" last revised 07/2017 revealed "...Patient Complaint......means an issue or concern verbally expressed by a patient, or the patient's representative, involving a relatively minor request, issue, or concern which can be resolved relatively quickly by Staff Present (as defined below). Such a complaint does not have to be treated as a Grievance (as defined below) unless the patient or the patient's representative requests the complaint be handled as a formal complaint or that there be a response from the hospital......Patient Grievance ("Grievance"): means a formal or informal written or verbal complaint communicated to a member of the NHI (Nash Hospital Inc.) Staff by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to NHI's compliance with the Centers for Medicare and Medicaid Services Hospital Conditions of Participation......Grievances specifically include, but are not limited to:... c. a verbal patient care complaint that cannot be resolved at the time of the complaint by the Staff Present, or is postponed for alter resolution, or requires investigation, and/or requires further actions for resolution......Patient Grievance Resolution: means: 1. that the Grievance has been investigated by the appropriate NHI Staff member; 2. the results of the grievance process, including NHI's decision have been communicated in writing ("Grievance Resolution Letter") to the patient, or the patient's representative, in a timely manner..."

Review on 08/16/2017 of the closed medical record for Patient #2 revealed a [AGE] year old female who arrived to the Emergency Department (ED) at 1703 on 04/11/2017 with a chief complaint of abdominal and chest pain. Patient #2 was triaged at 1715 on 04/11/2017. Review revealed Patient #2's vital signs at 1726 were temperature 36.8(C), blood pressure (BP) 112/62, respirations 18, heart rate (HR) 78 and oxygen saturation was 95% on 3 liters nasal cannula which Patient #2 wore at home. Review revealed Patient #2 rated her pain as 5/10 (moderate pain). Continued review revealed Patient #2 was brought back to a room at 2128 and vital signs were taken at 2140 which included: temperature 36.9, heart rate 70, respirations 22, blood pressure 134/49, and oxygen saturation 100% on 3 liters nasal cannula. Review revealed MD #2 (Medical Doctor #2) assessed Patient #2 at 2142 and ordered medication. Review of MD #2's recheck revealed "Recheck on patient. Discussed with patient and family ED findings and plan for admission to the hospital for further evaluation and/or workup. Patient and family understand and voice agreement for admission. Any questions have been answered..." Continued review revealed on 04/12/2017 at 0725 MD #3 admitted Patient #2. Review of MD #3's history and physical revealed "...past surgical history appendectomy......1. Abdominal pain...Noted to have right upper quadrant tenderness. Liver functions tests are negative. Will obtain an abdominal ultrasound...Chest pain. She will be placed on telemetry, ruled out for myocardial infarction with serial cardiac enzymes.....The patient as well as her family understand the care plan. All their questions have been answered..." Review of a nursing note written on 04/12/2017 at 1013 while Patient #2 was waiting in the ER for an inpatient bed revealed "PNT (patient) c/o (complains of) worsening pain...hospitalist will be notified." Review revealed an additional nursing note written at 1036 revealed "PNT remains very uncomfortable. BP elevated. Daughter at bedside...NP (nurse practitioner) called. Updated on PNT's pain level..." Review of a nursing note written at 1037 revealed "PNT appears much more comfortable after receiving PO (by mouth) fluids and dilaudid 0.5 MG (milligrams) IVP (intravenous push)..." Review revealed Patient #2 was admitted to the Cardiac Observation Unit (COU) on 04/12/2017 at 1035. Review of a nursing note by RN #3 written on 04/12/2017 at 1105 revealed "Patient c/o (complains of) of abdominal 'discomfort', abdominal tenderness on palpation noted to bilateral upper quadrants and right lower quadrant. Abdomen distended, BS (bowel sounds) hypoactive. Family at bedside with concerns, requesting to see physician. (MD #4) notified of patient assessment ...VSS (vital signs stable)." Continued review revealed MD #4 went to see Patient #2 and ordered an abdominal computed tomography (CT) scan. Review revealed the CT scan was completed on 04/12/2017 at 1414 (20 hours and 59 minutes after Patient #2 arrived) and revealed "...Changes of acute appendicitis with focal appendiceal perforation and mild adjacent air about the inflamed appendix..." Review of MD #4's addendum on 04/12/2017 at 1539 revealed "...ruptured appendix with abscess. Discussed with family and (MD #5). Rec (recommends) surgery." Continued reviewed revealed Patient #2 IV access was lost and a central line was placed at 1615 and Patient #2 was taken to the Operating Room (OR) for a laparoscopic appendectomy with abdominal washout at 1700. Review revealed Patient #2 was transferred to the Cardiovascular Intensive Care Unit (CVICU) post-operatively intubated at 2252 on 04/12/2017. Review of MD #4's progress note on 04/13/ at 0755 revealed "...Today's Information: s/p lap appy for perf with washout (status post laparoscopic appendectomy for perforation)......Plan: Should be able to extubate this morning, 25 minute discussion with family who are very concerned regarding delay in diagnosis..." Further review revealed Patient #2 stayed in the CVICU until she was transferred to a tertiary hospital. Review of the discharge summary written on 04/19/2017 at 1902 by MD #1 revealed "...Family decided they wanted to have her (Patient #2) transferred to (tertiary hospital) and I called, Dr. Chiang (MD at tertiary hospital) was very gracious to accept her and they will take her when she has a bed available..." Review revealed Patient #2 was transferred to a tertiary hospital at 0254 on 04/20/2017.

Review of the grievance log on 08/15/2017 revealed there was no grievance associated with Patient #2.

MD #2 was not available for interview

Interview on 08/16/2017 at 1610 with NM#1 (Nurse Manager #1) revealed he rounded on all patients in the CVICU daily. Continued interview revealed he talked to Patient #2's family when Patient #2 was admitted to the CVICU. Interview revealed family was upset with the ER (emergency room ) physician because Patient #2 had abdominal pain in the ER and a CT scan was not performed until much later (20 hours and 59 minutes). Continued interview revealed NM#1, NM#2, NM#3, RN #3 met with Patient #2's son and daughter while Patient #2 was hospitalized and discussed the family's concerns with Patient #2's care. Interview revealed Patient #2's family wanted to know how this "delay in care" would not happen to another patient. NM #1 revealed Patient #2's chart could be peer-reviewed by physician staff. Continued interview revealed Patient #2's family said that they were okay with that. Interview revealed NM#1 felt the issue was resolved after the meeting and did not feel it was a grievance. Continued interview revealed there was no documentation of this meeting. Interview revealed when NM#1 rounded on Patient #2 and her family after the meeting they brought up the same concerns again.

Interview on 08/17/ at 0905 with MD #4 revealed he was the MD that ordered a CT scan for Patient #2. Interview revealed when he first met Patient #2 and her family he sat down and did an extensive review of systems, which is what prompted him to order an abdominal CT. Continued interview revealed Patient #2's family was concerned about her having a low blood pressure in the ER and asking for a CT scan in the ER and it not being done. Continued interview revealed he continued taking care of Patient #2 after she was transferred to the CVICU post-operatively. Interview revealed the family of Patient #2 had multiple questions about whey a CT scan was not done earlier. Interview revealed MD #4 spoke to the physicians involved in Patient #2's case on the day Patient #2 was diagnosed with a perforated appendix.

Interview on 08/17/2017 at 0950 with MD #1 revealed she took care of Patient #2 "about 3-4 days" prior to her transfer. Interview revealed Patient #2's family was always "adamant" that if she would have been treated earlier she would have recovered better. Continued interview revealed her family spoke about wanting Patient #2 transferred and she assisted with that. Continued interview revealed MD #1 had long conversations with Patient #2's family and they felt that no one was listening to them in the ER when she first arrived. Continued interview revealed MD #1 updated Patient #2's family during her morning rounds when they were in the room about the plan of care.

Interview on 08/17/2017 at 1035 with RN #3 revealed she took care of Patient #2 when she was admitted to the COU. Interview revealed when Patient #2 arrived to the COU Patient #2's son and daughter accompanied her and were concerned about her. Interview revealed RN #3 called MD #4 regarding the concerns. Continued interview revealed RN #4 told NM #2 that Patient #2's son and daughter wanted to speak to someone in management about their concerns. Interview revealed RN #3 met with Patient #2's family with other nurse managers and discussed their concerns. Interview revealed during the meeting Patient #2's family voiced concerns about Patient #2's care.

Interview on 08/17/2017 at 1100 with NM #2 revealed she was called by RN #3 to speak to Patient #2's family because they had concerns. Interview revealed Patient #2's family's main concerns was the lack of care Patient #2 received in the ER. Interview revealed when Patient #2 was transferred to the CVICU NM #2 informed NM #1 and set-up a meeting with Patient #2's family. Interview revealed the meeting included NM#1, NM#2, RN #3, and NM#3 because NM#2 wanted to get everyone who had been involved in Patient #2's care on the same page. Interview revealed during the meeting Patient #2's family was upset that their concerns about Patient #2 were not addressed in the ER and they wanted to know how a delay in care like this would not happen again. Interview revealed the nurse managers discussed with Patient #2's family that they could send Patient #2's chart for a peer review by physicians. Interview revealed NM #2 thought that concerns were resolved after the meeting concluded.

Interview on 08/17/2017 at 1200 with NM #3 revealed she was the nurse manager for the ER. Interview revealed she was not involved in Patient #2's care but was in the meeting with Patient #2's family about their concerns with her care. Interview revealed during the meeting Patient #2's family discussed their concerns about the wait times, and the bedside manner of the provider in the ER. Interview revealed NM #1 and NM #2 rounded on Patient #2 and her family when they worked. Interview revealed there was no documentation associated with this meeting.

Interview with Quality Director #1 revealed a Joint Commission complaint was received in June 2017 in regards to Patient #2. Interview revealed since June 2017 the facility have made changes. Interview revealed no follow up with staff and staff education was done prior to June 2017 regarding Patient #2 family's concerns. Continued interview revealed if staff have to address the same issue or complaint multiple times then it should be considered a grievance. Continued interview revealed there was no grievance or written response to a grievance associated with Patient #2 .

NC 897