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SAMPSON REGIONAL MEDICAL CENTER 607 BEAMAN ST CLINTON, NC 28328 May 6, 2021
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, variance report review, response letter review and staff interviews, (a) the facility staff failed to document a grievance per policy in 1 of 1 sampled grievance (Patient #1) and (b) failed to identify a patient complaint as a grievance in 2 of 3 sampled patients (Patient #9 and #11).

The findings included:

Review of the policy and procedure titled "Patient Complaint and Grievance Resolution Process" effective 03/27/2015 revealed "Policy: (Named Hospital) attempts to resolve all grievances as soon as possible...Definitions: A. Complaint: 1. A concern regarding patient care or service expressed by the patient or patient's representative that can be resolved at the point of service by the staff present...B. Grievance: Complaints which are to be considered grievances include: 1. Patient care issues which are not promptly resolved by staff present ...Procedure:...M. All final forms, letters and documentation will be sent to the Risk Manager for the file. The Risk Manager will document information in the Variance Database and maintain the file..."

A. Closed Medical record review revealed Patient #1 was a [AGE]-year-old female who underwent a cholecystectomy (removal of the gallbladder) on 02/22/2021 and transferred to PACU (post-anesthesia care unit) at 1240. Review revealed Patient #1 was discharged from PACU on 02/22/2021 at 1440. Review revealed Patient #1 returned to the Hospital's Emergency Department (ED) on 02/22/2021 at 1759 for "evaluation of drainage tube. She had lap chole (laparoscopic cholecystectomy) this morning and was sent home with drainage tube in the right upper abdomen...RN (registered nurse) taught daughter how to empty bulb..." Patient #1 was discharged from the ED on 02/22/2021.

Request for Patient #1's grievance revealed there was no documentation available for review other than the response letter dated 03/01/2021. Review of the response letter revealed a response was sent from the Director of Risk and Compliance to Patient #1's daughter (the one who filed the grievance). Review of the response letter revealed "I shared her experience with our Chief Medical Officer, as well as our Chief Nursing Officer and the Director of Surgical Services. We are investigating materials related to JP (drain tube Patient #1 had) drain education..."

Interview on 05/06/2021 at 1325 with the Director of Risk and Compliance revealed she documented Patient #1's daughters' complaint on a sheet of paper the day she called (02/24/2021). Interview revealed Patient #1's daughter was concerned staff failed to educate her on how to care for the JP drain. Interview revealed the Director shared the daughters' concerns with the Director of Surgical services however, there was no file or documentation related to Patient #1's grievance. Interview revealed Patient #1's grievance was not documented in the variance system due to the Director "got behind."

B1. Closed medical record review revealed Patient #9 was a [AGE]-year-old male admitted on [DATE] for blood transfusion and sepsis (your body's response to an infection). Review revealed on 02/10/2021 at 0559 Patient #9's Hgb (hemoglobin-red protein responsible for transporting oxygen in the blood) was 6.9 (normal 12.5-16.3). Review revealed Patient #9 received two units of blood on 02/10/2021 at 1235 and 1619. Review revealed no additional Hgb on 02/10/2021 prior to discharge. Review revealed Patient #9 was discharged back to the nursing home he resided at 1858.

Review of a Variance report dated 02/10/2021 at 2230 revealed "Event Code: Complaint ...Detailed Description: Patient family called 3 central tonight to get update on her dad. Patient had been discharged to (Named Nursing Facility) tonight at 1900 and the family had not been notified. Patient #9 received 2 units of blood today for Hgb of 6.9, H&H (hematocrit and hemoglobin) not checked prior to discharge. Tammy (patient's son [sic]) was disappointed that no one had called the family with an update today and notified them the patient being discharged from the hospital ...She is also questioning why a hgb was not checked prior to his discharge. I told her I would have (Named) Dr. call her tomorrow to speak to her concerns. I will send them an email, as well as leave a message with the CA..." (clinical administrator).

Interview on 05/06/2021 at 0910 with the Director of Risk and Compliance revealed when she had a conversation on the phone and discussed what she was going to do for a complainant, she felt there was resolution. Interview confirmed there was no follow-up with a complainant with outcomes. Interview revealed no resolution letters nor acknowledgment letters were sent since incidents were identified as complaints. Interview revealed the Director had reviewed the Joint Commission and CMS (Centers for Medicare & Medicaid Services) crosswalk during current survey and now had a better understanding of the regulations.








B2. Closed medical review revealed Patient #11 a [AGE] year old female who presented to the facility's emergency department for chest pain and shortness of breath. Review revealed patient was diagnosed with a non ST elevation myocardial infarction (heart attack). Patient #11 was stabilized and transferred to a hospital with interventional cardiac services.

Review of Patient #11 complaint dated 04/16/2021 at 0821 revealed "Details of Event On 04/09/21 received a call from patient....She states the receptionist called to the triage immediately as she is supposed to, to make her aware she has c/o (complaints of) chest pain and SOB (shortness of breath)- she states she waited over 30 minutes to be seen and she feels the triage nurse did not believe her... I called her back... I also made her aware her care would be reviewed with the ED Director and Quality."

Interview on 05/06/2021 at 0910 with the Director of Risk and Compliance revealed when she had a conversation on the phone and discussed what she was going to do for a complainant, she felt there was resolution. Interview confirmed there was no follow-up with a complainant with outcomes. Interview revealed no resolution letters nor acknowledgment letters were sent since incidents were identified as complaints. Interview revealed the Director had reviewed the Joint Commission and CMS (Centers for Medicare & Medicaid Services) crosswalk during current survey and now had a better understanding of the regulations.

NC 963