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THE MOSES H CONE MEMORIAL HOSPITAL 1200 N ELM ST GREENSBORO, NC 27401 March 14, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, email correspondance and staff interview, the hospital staff failed to identify an allegation of neglect as a grievance and follow the investigation process for 1 of 4 sampled discharged patients (Patient #8).

The findings included:

Review of the policy titled "Patient Grievance Management Process", effective 10/19/2018 revealed, "...recognizes that patients have the right to voice concerns ...and to have these concerns reviewed and addressed in a timely manner. ... (Hospital) seeks to provide prompt review and timely resolution of complaints and grievances from a patient. ...DEFINITIONS: A patient grievance is a formal or informal written or verbal complaint by a patient or patient's authorized representative regarding (1) the patient's care, (2) abuse or neglect, (3) issues related to the facility's compliance with the CMS Hospital Conditions of Participation (COP) ... Examples of Patient Grievances ... 2. All verbal complaints regarding patient care from a patient or patient's representative that cannot be immediately resolved and are delayed, referred, require more investigation, or require further action for resolution. 3. All verbal allegations of abuse, neglect, patient harm ... or non-compliance with COPs. ... Response to a Grievance 1. All grievances are forwarded to the Clinical Compliance and Regulatory Services. 2. Clinical Compliance and Regulatory Services ensures the process and timing of the grievance is followed. ...4. Within seven business days, Clinical Compliance and Regulatory Services or ...leadership will contact the patient or representative to address resolution or to inform the patient or representative that further investigation is required. The patient or representative will be informed of the expected follow-up time to resolve the grievance. All grievances will be resolved as soon as possible ... 5. The resolution of all grievances investigated....will provide the patient or legal representative written notice of the decision. The notice will contain the name of the contact person, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance process, and the date of completion. ..."

Closed medical record review for Patient #8, on 03/12/2019, revealed the [AGE]-year-old was admitted [DATE] at 0831. Review of the History and Physical (H&P) note, at 1156, "... presenting with diffuse abdominal pain, nausea, and vomiting. She also has [sic] hypertensive urgency in the ED (Emergency Department)." The Past Medical History (PMH) included a recent NSTEMI (Non-ST-elevation myocardial infarction: Heart Attack) [DIAGNOSES REDACTED], catheter associated urinary tract infection (UTI), Diabetes, right above the knee amputation (AKA) and End Stage Renal Disease (ESRD). Review of the chest x-ray (CXR) in the ED revealed pulmonary edema (fluid in the lungs) and Congestive Heart Failure (CHF). Review of nursing progress notes revealed Patient #8 received dialysis 01/21/2019, 01/23/2019, 01/24/2019 and 01/25/2019 prior to discharge at 1705.

Review on 03/13/2019 of a historical weather report, on 01/24/2019, revealed the high for the day was 45 degrees Fahrenheit (F).

Review on 03/14/2019 of a printed email correspondence, dated 01/28/2019 at 1033, from the Patient Relations Supervisor (PRS) revealed, "I just received a call from....a nurse practitioner (NP) ... She contacted our office to discuss the discharge of (Patient #8). (NP) stated that the patient was wheeled outside in her pajamas and house shoes and left to wait in the cold until her (family member) came to get her. She stated that the patient was very upset and when her (family member) arrived, he and the staff exchanged words about her discharge. ... I did reach out to the patient directly to hear specifically from her about this experience and to let her know that her NP contacted us to report this. ..."

Review on 03/14/2019 of a printed email correspondence, dated 01/28/2019 at 1153, from the Nurse Manager (NM) of the unit where Patient #8 was discharged from revealed, "... I'm sorry that this occurred I think there are some family dynamics between him having to pick her up and care for her etc. ... Not for us to fix but I'm sure a piece of the story for his frustrations. ... I'm sorry she was cold while waiting on her (family member). ..."

Interview on 03/13/2019 at 1200 with the NM revealed that she heard a comment, "in passing" (no date or time) from a staff member (unable to recall name), about the patient's family member calling the unit on 01/25/2019 (no specified time), "yelling at us" (about the patient being outside when he arrived to pick her up at discharge). Interview revealed the NM received a phone call from the Office of Patient Experience, sharing a call had been received from the patient's family member verbalizing "concerns about the patient being out in the cold at discharge." Interview revealed the NM conducted a chart review and spoke with the nurse who discharged the patient (RN #1). According to the NM, a Nurse Technician (NT) #1 escorted the patient downstairs for discharge with a robe, pants, and socks on, and a blanket draped around her, because she did not have a coat. "The patient told the NT that her (family member) had been waiting an hour," she said. Interview revealed when NT #1 took the patient down for discharge, NT #1 rolled her outside, for "approximately 5 minutes," but the family member was not there. Interview revealed when the family member drove up, he "yelled at (NT #1), Why do you have her (Patient #8) out here in the cold?" NT #1 assisted the patient into the vehicle. Interview revealed, "By the time the NT (#1) got back up to the unit, the (family member) had called the unit, yelling at the charge nurse (upset that patient was outside in the cold, waiting to be picked up instead of inside the building when he arrived). I emailed the Office of Patient Experience Specialist (OPES) to let them know that I'd followed up." The NM shared the patient may have waited to be picked up, "maybe 5-10 minutes."

Interview on 03/12/2019 at 1515 with the Director of Quality revealed the patient should have been taken back into the heated waiting area to wait for her transportation as opposed to waiting out in the cold weather.

Interview on 03/13/2019 at 1600 with NT #1 and NM revealed she assisted another NT (#2) to get the patient dressed for discharge. The NT shared the patient told her that her "(family member) had been waiting an hour, and that he was livid (furiously angry)." Interview revealed the patient was dressed in "fuzzy pink pants, no shirt, by choice", a robe, a sock, with no shoe or coat. Interview revealed Patient #8 did not have a shirt, shoe or coat from home and declined a hospital gown or scrub top. NT #1 indicated a blanket was used to drape around the patient, since she did not have a coat, "to keep her warm." Interview revealed when NT #1 rolled the patient down to the lobby, the NT took her outside because the patient reported that her family member had been "waiting an hour". The NT revealed the family member was not there and instead of taking the patient back into the heated waiting area, the two waited outside "5-7 minutes, no more than 10 minutes." Interview revealed when the family member arrived, he got out of the vehicle, "Yelling, I can't believe you have a cancer patient out here in the cold with no coat on." The NT stated that by the time she got back to the unit, the family member had called and shared his concern about the patient being out in the cold when there was a heated waiting area available. Interview revealed NT #1 did not think about having the patient outside and that the patient did not complain of being cold. "If I had to do it over, I would've brought her back into the lobby and waited until I saw him (family member) pull up.

Interview on 03/14/2019 at 0915 with the Director of Quality revealed a call (no date or time provided) was received from an outside dialysis center. The call "wasn't from the patient or patient's family and we never reached her (patient) to see if she wanted us to enter a grievance on her behalf. Interview revealed the patient, family member, or guardian were considered an "authorized patient representative". If a grievance is filed by another individual, the hospital's practice was to send a follow up response as outlined in the grievance management policy, to the patient and not the individual filing the grievance, "due to privacy concerns. We attempted to reach the patient. The part where the (family member) called the unit, nor the patient's reported concern about going home with the family member, didn't get to the grievance team. This is the first I'm hearing about it," she said. Interview revealed, "I think this is an area of opportunity for us. I was not aware the (family member) called the unit and complained or that she (the patient) told the NT she was afraid to go home. We should've investigated and sent a letter to the patient and apologized (for having her wait outside)." Interview revealed further investigation into the reported concerns was warranted and would occur.

NC 015