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.

Based on interview and record review, the facility failed to notify the patient of the decision pertaining to his complaint for 1 patient reviewed for grievances (#1).


On 4/30/19 at 10:59 AM, the risk manager (RM) said on 4/08/19 a complaint from a post discharge phone call was received from patient #1. The patient stated he received sedation in the cardiac catheter (cath) lab after telling staff he has violent reactions to sedation. The RM stated the patient became verbally aggressive with staff and left against medical advice (AMA) after his cardiac catheterization. The RM said after staff spoke to patient #1 on the phone after leaving AMA, the patient said did not recall most of the evening. He stated he remembered being nasty to the nurse, and walking over the causeway trying to get back to his boat, does not recall how he got to his boat or leaving the hospital. The patient said he called the doctor's office and was told that he needed to find another cardiologist. The RM said the patient was concerned that he was able to leave the hospital while "under the influence" of medications, and was concerned that he had harmed staff while under this influence as well.

Actions taken by the facility were: the complaint was reviewed by the "Complaint and Patient Experience" committee on 4/09/19. Interviews were conducted with the cath lab staff, who reported no aggressive behavior by patient #1. the conclusion was, based on the patient signing AMA after another prior cath in 2017, medications should have fully cleared. Based on prior records, patient #1 should have been capable and medication effects would have worn off at the time the patient left AMA on 4/09/19.

The medical doctor (MD) was not interviewed and the patient was not contacted regarding the decision/resolution to his grievance.

On 4/30/19 at 10:59 AM, the RM said the committee was focused on the statement of the patient, that he had harmed someone while under the influence. The committee did not follow-up on comment regarding the MD, and the patient was not contacted to inform him of what resolution was reached. The RM said it was a "norm" to follow up and send a letter, but in this case, a letter was not sent because patient #1 lived on a boat. The committee did not call the patient or inquire if the patient had a post office box number. The RM said the complaint was closed, and this was not a satisfactory response to the patient's complaint.

The facility's policy and procedure "Patient & Family Complaint and Grievance Policy", # RM1.19 Effective 9/2011 Revised/reviewed 4/2016 read, ".3. Once an associate has been made aware of a complaint, that associate must either address the issue or forward it to the appropriate department Manager or Director. That receiving Manager or Director must make every reasonable attempt to resolve the complaint. A suggested method of resolution is to: *Interview the complainant and pertinent parties *Determine action needed by the appropriate department *Discuss potential resolution with all parties, conduct necessary follow-up. 4. If the complainant is not satisfied with the response from either of these parties, the complainant may request that the complaint be addresses at another level. At this time the issue must be forwarded to Patient Advocate for review and resolution through the Grievance Committee".

Patient #1 was not informed of the resolution to his complaint, so the facility did not know if the patient was satisfied with their response.

Based on interview and record review, the facility failed to immediately complete an operative report for 1 of 3 patients reviewed for surgical procedures (#1).


Patient #1 is a [AGE] year-old with a past medical history of cardiac disease. On 4/05/19, a right groin cardiac catheterization was performed on the patient. Record review showed that an operative report was not completed by the surgeon. A procedure timeline was done by the cardiac catheterization lab staff, but an operative report was still required by the surgeon. None could be identified. "Cardiac catheterization is a procedure used to diagnose and treat cardiovascular conditions. During cardiac catheterization, a long thin tube called a catheter is inserted in an artery or vein in your groin, neck or arm and threaded through your blood vessels to your heart." (Mayo Clinic).

On 4/30/19 at 10:46 AM, the vice president (VP) of nursing said she could not locate the operative report for procedure performed on patient #1. The VP said she was in the process of reaching out to the surgeon regarding the operative report. She verified that as per the Medical Staff Bylaws, an operative report should be documented within 24 hours of the procedure.

The facility's policy and procedure "Medical Record Content Requirement", effective 07/2001 Revised 09/2017, pg 7 of 10 read, "Q. Operative and other Invasive Procedures. 1. The medical record thoroughly documents operative or other invasive procedures and the use of sedation or anesthesia....3. Operative reports dictated or written immediately after surgery record the name of the primary surgeon and assistants, findings, technical procedures used, specimens removed, estimated blood loss, complications, if any, preoperative diagnosis and postoperative diagnosis. 4. The completed operative report is authenticated by the surgeon and filed in the medical record as soon as possible after surgery. 5. When the operative report is not placed in the medical record immediately after surgery, a progress note is entered immediately.

The Medical Staff Bylaws, Policies, and Rules and Regulations of Care: adopted by the Medical Staff: September 19, 2006, revised by the Medical Staff June 22, 2010, approved by the Board May 27, 2009, revision June 28, 2018 Page 4 of 7. 9b read, "A brief operative or procedural note must be entered into the record immediately following a surgical or other invasive procedure before the patient is transferred to the next level of care and shall contain the components set forth in hospital policy. Operative reports and procedure reports are to be dictated into the medical record within twenty-four (24) hours and shall contain the components set forth in hospital policy."

The operative report was completed and signed by the surgeon on 4/30/19 at 12:05 PM. The procedure for pt #1 was completed on 4/05/19.