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.

EASTERN OKLAHOMA MEDICAL CENTER 105 WALL STREET POTEAU, OK Aug. 8, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. Findings:

The hospital grievance policy specified when a written response would be provided to a complainant regarding a grievance.

A form entitled Patient Bill of Rights and Non Discrimination Policy stipulates "patient's have the right to voice your complaints or grievance regarding care received, to have those issues revieed and when possible resolved. This shall be without fear or retribution. The complaint or grievancemay be verbally or in writing. Should the patient/family wish to file a formal complaint, please contact Nursing Administration." The form lists several different phone numbers and contacts for patients to bring their concerns to. There is no evidence the facility provides this document at admission or during the stay.

On 8/8/13 during a tour of the emergency room , the surveyor requested the attendant to provide all of the documentation regafing patient rights and grievances. None of the documents included all of the information the patient rights policy stipulated would be provided to the patinet.

The hospital provided a list of four grievances for 2012 to present. Not all of the complainants recieved written notification, investigations steps and steps taken on behalf of the patient. There was no further evidence of a written response to the complainants of the results of any investigation and actions taken
One grievance response listed was related to HIPAA privacy and no letter was sent.

The hospital incident log was requested for 2013. The record indicated only about eight incidents had occurred for the current year. One of the incidents should have been a grievance. The hospital did not provide any further documentation of investigation and follow-up to these grievances. Staff A stated no other documentation could be located.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of hospital policy, meeting minutes, and interviews with personnel. The hospital failed to correctly identify grievances. The hospital does not ensure all grievances are reviewed by the Governing Body or a Committee appointed by the Governing body. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

1. On 8/8/2013 surveyors reviewed the facility grievance policy. The policy "Patient Grievance" does correctly define a grievance. Further the policy stipulates each patient is given a patients Bill of Rights outlined within that document (sic) the grievance process for Eastern Oklahoma Medical Center. It includes how to contact the Oklahoma State Department of Health, .....CMS, and Joint Commission". with all the required elements. Upon review of the patient bill or rights provided, the information the policy stipulated is not included in the handout. The surveyor also toured the emergency department. There was no additional information provided in the emergency room waiting area or on the admission forms. This finding was verified with Staff A.

2. The policy further stipulates the "grievance committee shall be delgate (sic) the responsibility for the operation of the grievance process by the hospitals governing board. The committee will consist of the CEO, CNO, and representatives from nursing and ancillary departments. This committee will meet to review grievances at least quarterly and as needed to follow up on matters that require more investigation". Although the policy stipulates there will be formalized meetings, there was no documentation of a grievance committee reviewing and submitting documentation to the governing body.
In an interview on 8/8/13 in the afternoon, Staff A told the surveyor members of leadership reviewed the grievances but there was nothing written.

3. Review of the Governing Body Meeting Minutes 2013 did not have any information regarding grievances. This finding was verified with Staff A. There is no formalized process where all grievances are reviewed through the governing body or a committee appointed by the governing body. There is no documentation the facility uses grievances and complaints to improve care.

2. On 08/8/2013 surveyors reviewed four complaint/grievances (#1,2,3,4). The surveyor also reviewed several incidents. The documents listed as grievances did not have all of the required elements of response to the complainant. One incident reviewed was a grievance and was not taken through the grievance process. There was no documentation all of the grievances were investigated and what steps were taken on behalf of the patient.

3. On 08/8/2013 surveyors reviewed incident report logs from July 2013-current. Four incident reports were reviewed. Two of the four incident reports selected required investigation into patient care issues/complaints. These incident reports were not included on the grievance log. There was no documentation the facility treated these incidents as grievances. There was no documentation this complaint was handled as a grievance.

4. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care. There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

5. There was no evidence the Governing Body reviewed, trended, and analyzed all incident, grievance, and complaint data.

6. This information was provided to administration at the exit conference. No further information was provided.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on policy and procedure review, record review and staff interview, it was determined the hospital failed to ensure grievances were reviewed, analyzed and trended, and failed to ensure the results of the analysis were reported to QAPI committee for further recommendations and actions.

1. A hospital policy, "Patient Grievance 9/07" stipulates "Grievance committee shall be delegate (sic) the responsibility for the operation fo the grievance proces by the hospitals governing board. The committee will consist of the CEO, CNO, and representatives from nursing and ancillary departments. This commitee will meet to review grivances at least quarterly and as needed to follow up on matters that requirem more investigation."
2. There was no documentation of a grievance committee meeting. Staff A told the surveyor usually the leadership team met and discussed anything that was considered a grievance. There was no process for review and documentation of investigation and actions taken on behalf of the patient. This finding was verified with Staff A.
3. There was no documentation the governing body reviewed grievance, complaints, and incidents. This finding was verified with Staff A.
4. There was no documentation the grievance and complaint information was reviewed and analyzed to improve care. This finding was verifed with Staff A.
5. There was no documentation in 5 of 5 (Staff C,D,E,F,G) staff members education files that Grievance, Complaint, and Incident reporting training occurred.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on record review, policy and procedure review and patient interview, it was determined the hospital failed to provide patients and/or their representatives with information on how to submit a grievance to the hospital. Findings:

10 patient records were reviewed. There was no documentation patients had been given information concerning the grievance process.

1. On 8/8/2013 surveyors reviewed the facility grievance policy. The policy "Patient Grievance" does correctly define a grievance. Further the policy stipulates each patient is given a patients Bill of Rights outlined within that document (sic) the grievance process for Eastern Oklahoma Medical Center. It includes how to contact the Oklahoma State Department of Health, .....CMS, and Joint Commission" with all the required elements.

Upon review of the patient bill or rights provided to the surveyor and during the tour of the emergency room , the information the policy stipulated is not included in the handout. The surveyor also toured the emergency department. There was no additional information provided in the emergency room waiting area or on the admission forms.

2. This above finding was verified with Staff A.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to review, analyze, and trend incidents, grievances, and complaints in order to develop plans to improve patient safety and clinical performance.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2013, Governing Body Meeting Minutes, and Medical Staff Meeting Minutes did not include analysis of incidents, grievances, and complaints to identify patterns which might impair patient safety. There was no analysis to develop plans of correction to improve patient safety.

2. Surveyors reviewed personnel files on 8/8/2013. There was no documentation the employees were educated on the current grievance policy/process. There was no documentation the employees were educated on incident reporting and medication error reporting.

3. Incident and grievance logs were requested for 2013. Surveyors found minimal reporting of incidents, grievances, and complaints. This was reviewed Staff A. Staff A told surveyors grievances, compliants, and incidents most likely are under reported. Staff A told the surveyor she was not sure of the training staff received regarding the definitions and processes. There were no documents provided incorporating all of the steps of incident/complaint and grievance reporting. Surveyors could not find documentation which stipulated grievances, complaints, and incidents were reviewed and analyzed to improve care.

4. This finding was discussed at the exit conference. No further documentation was provided.