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.

JEFFERSON HEALTH- NORTHEAST 10800 KNIGHTS ROAD PHILADELPHIA, PA 19114 March 4, 2020
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure a formal written complaint/grievance was reviewed and resolved as per facility policy for 1 of 1 complaint/grievance reviewed.

Findings include:

Review on March 3, 2020, of facility's policy, "Complaint-Grievance," dated 2/18/2019, revealed, " ... III. Definitions: ... C. Grievance-Is an unresolved complaint ... VI. Procedure: Telephone Communication Procedure- 1. Complaints that are received by phone are referred to the Patient Relations Department if resolution is not possible by the individual receiving the call ... the complainant should receive a return phone call from the patient relations department within 72 hours ... 3. The complaint will be entered into the event reporting system within 7 days of receiving the complaint ... 4. A letter of acknowledgement of the complaint or concern will also be sent to the patient ... by the patient relations department within 7 days of receiving the complaint ... D. Investigation and Response- 1. The patient relations department manager ... will in coordination with other possible departments ... investigate the concern or grievance and will formulate a response to the patient ... 2. Information concerning the investigation will be added to the electronic reporting system by the person doing the investigation on the event ... 4. The final closure and response will be completed and recorded in the event reporting system and sent by the patient relations department manager or signee within thirty days of the receipt of their complaint ... 8. The hospital must maintain all documentation of its efforts ... 9. ... The written response must provide ... steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion ... ."

Review on March 3, 2020, of facility email between patient relations staff dated October 16, 2019, revealed complainant called to complain about ED visit on 10/15/2019. Further revealed this was forwarded to EMP4 to follow-up.

Review on March 3, 2020, of facility email between patient relations staff dated October 25, 2019 at 11:00 AM, revealed " Negative Review Alert." Further revealed complainant wrote a negative review on facility's website related to ED visit on 10/15/2019. Further revealed this was forwarded to EMP4 to follow-up.

Review on March 3, 2020, of facility's email between patient relations staff dated October 25, 2019 revealed EMP4 aware of complaint from 10/16/2019 and stated in email "will reach out to patient again-today"

Review on March 3, 2020, of letter from facility to complainant, dated October 22, 2019 revealed complaint related to ED visit on 10/15/2019 was acknowledged and stated " ... the concerns that you shared with ... and myself [EMP4] was shared with the appropriate teams to review and address with their staff ... ."

Request was made to EMP1 on March 3, 2020 for complaint-grievance investigation report of patient's complaint/grievance related to ED visit on 10/15/2019 and evidence it was entered into the event system. None provided.

Interview on March 3, 2020, with EMP1, at approximately 11:00 AM confirmed Complaint-Grievance Policy was not followed in this case as a result the event was not entered into the reporting system when complaint was initially received on 10/16/2019 and again on 10/25/2019 via website, the complainant did not receive a return phone call within 72 hours, no documentation of investigation, no final closure letter with documentation to include: steps taken to investigate the grievance, results of the grievance process and the date of completion. Further confirmed not sure exactly what happened in this event because so much time has passed since event, but can only assume based on patient's report.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to provide patient with a written notice of its decision per policy for 1 of 1 medical record reviewed (MR1).

Findings include:

Review on March 3, 2020, of facility's policy, "Complaint-Grievance," dated 2/18/2019, revealed, " ... III. Definitions: ... C. Grievance-Is an unresolved complaint ... VI. Procedure: Telephone Communication Procedure- 1. Complaints that are received by phone are referred to the Patient Relations Department if resolution is not possible by the individual receiving the call ... the complainant should receive a return phone call from the patient relations department within 72 hours ... 3. The complaint will be entered into the event reporting system within 7 days of receiving the complaint ... 4. A letter of acknowledgement of the complaint or concern will also be sent to the patient ... by the patient relations department within 7 days of receiving the complaint ... D. Investigation and Response- 1. The patient relations department manager ... will in coordination with other possible departments ... investigate the concern or grievance and will formulate a response to the patient ... 2. Information concerning the investigation will be added to the electronic reporting system by the person doing the investigation on the event ... 4. The final closure and response will be completed and recorded in the event reporting system and sent by the patient relations department manager or signee within thirty days of the receipt of their complaint ... 8. The hospital must maintain all documentation of its efforts ... 9. ... The written response must provide ... steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion ... ."

Review on March 3, 2020, of facility email between patient relations staff dated October 16, 2019, revealed complainant called to complain about ED visit on 10/15/2019. Further revealed this was forwarded to EMP4 to follow-up.

Review on March 3, 2020, of facility email between patient relations staff dated October 25, 2019 at 11:00 AM, revealed " Negative Review Alert." Further revealed complainant wrote a negative review on facility's website related to ED visit on 10/15/2019. Further revealed this was forwarded to EMP4 to follow-up.

Review on March 3, 2020, of facility's email between patient relations staff dated October 25, 2019 revealed EMP4 aware of complaint from 10/16/2019 and stated in email "will reach out to patient again-today"

Review on March 3, 2020, of letter from facility to complainant, dated October 22, 2019 revealed complaint related to ED visit on 10/15/2019 was acknowledged and stated " ... the concerns that you shared with ... and myself [EMP4] was shared with the appropriate teams to review and address with their staff ... ."

Request was made to EMP1 on March 3, 2020 for complaint-grievance investigation report of patient's complaint/grievance related to ED visit on 10/15/2019 and evidence it was entered into the event system. None provided.

Interview on March 3, 2020, with EMP1, at approximately 11:00 AM confirmed Complaint-Grievance Policy was not followed in this case as a result the event was not entered into the reporting system when complaint was initially received on 10/16/2019 and again on 10/25/2019 via website, the complainant did not receive a return phone call within 72 hours, no documentation of investigation, no final closure letter with documentation to include: steps taken to investigate the grievance, results of the grievance process and the date of completion. Further confirmed not sure exactly what happened in this event because so much time has passed since event, but can only assume based on patient's report.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on review of facility documents and staff interview (EMP) it was determined the facility failed to follow their own triage policy as evidenced by failure to complete registration and triage for 1 of 1 medical record reviewed (MR1).

Findings include:

Review on March 3, 2020, of facility's policy, "Triage," dated 2/16/2017, revealed " ... VI. Procedure: A. Plan: 3. Patients presenting to main Emergency Department for Triage via Emergency Medical Services (EMS) will have a rapid triage assessment with name, date of birth, and chief complaint entered into the medical record. If immediate bedding is not available after rapid triage, the patient will be taken to waiting room by EMS ... ."

Review on March 3, 2020, of ambulance record dated 10/15/2019 related to MR1's ED visit, revealed pt [patient] arrived via ambulance at facility at 4:30 PM. Further revealed, " ... 49 yom [year old male] with cc [chief complaint] of not being able to urinate ... pt stated that he has rib pain with the not being able to pee ... pt rated rib pain 3/10 ... pt had no other complaints ... loaded pt into truck, vitals were taken and noted ... continued to monitor pt to hospital, arrived at hospital, report was given to nurse ... ." Further revealed "Pulse is 88," "Respiratory rate 16," "Blood pressure 150/Palpated," "Total GCS [Glasgow Coma Scale] 15."

Review on March 3, 2020, of facility's ED Log dated 10/15/2019 revealed 137 patients were seen in ED [emergency department] that day. Further revealed, patient related to MR1 was not listed.

Review on March 3, 2020, of facility email between patient relations staff dated October 16, 2019, revealed patient related to MR1 called to complain about ED visit on 10/15/2019. Further revealed " ... left after 90 minutes of waiting ... ."

Review on March 3, 2020, of facility email between patient relations staff dated October 25, 2019 at 11:00 AM, revealed " Negative Review Alert." Further revealed patient related to MR1 wrote a negative review on facility's website related to ED visit on 10/15/2019. Further revealed this was forwarded to EMP4 to follow-up.

Interview on March 3, 2020, with EMP1, at approximately 11:00 AM confirmed per ambulance record patient related to MR1 arrived to facility on October 15, 2019 at 4:30 PM, but was not on Emergency Department log for that date. Further confirmed triage policy was not followed in this case, as a result patient was not registered in ED Log and triaged.