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SELECT SPECIALTY HOSPITAL - CENTRAL PA HARRISBURG
PATIENT RIGHTS: REVIEW OF GRIEVANCES
Tag No.: A0119
Based on a review of Medical Staff Bylaws, facility documents, and interviews with staff (EMP), it was determined Select Medical at Polyclinic Medical Center failed to follow their adopted process in relation to complaints received regarding physician services.
Findings include:
A review on November 29, 2010, of "Medical Staff Bylaws", revised 2/15/10, revealed "6.C: Investigation Process, (1) The Chairperson of the Governing Board, the Chief Executive Officer or the Medical Director may, upon receipt of a complaint about a member of the Medical Staff, and after review of the same to determine its credibility, make a written request that the Medical Executive Committee investigate the complaint. (2) The Medical Executive Committee shall meet as soon as possible after receiving a request for an investigation. The Medical Executive Committee shall review the request and any supporting documentation and determine whether there is a need to conduct an investigation. An investigation shall begin only after the Medical Executive Committee has passed a resolution to that effect. (3) Upon adoption of a resolution, the Medical Executive Committee shall immediately begin to investigate the matter. The Committee shall have the discretion to conduct the investigation itself or appoint an ad hoc committee to do so. ..."
1) A review of facility documentation on November 29, 2010, revealed the facility had received a formal complaint regarding the physician care provided to a patient in December 2009.
2) An interview with EMP1 on November 29, 2010, at approximately 3:30 PM, revealed " When I received this complaint I contacted our legal department and they felt this case needed to go to physician peer review. I took the medical record to two different physicians for peer review. The Medical Director felt there was a conflict of interest and wanted the review to go to an outside hospital. One doctor took a look at the record and only thing they questioned was the lithium level. They did not document anything. No root cause analysis was done. The case was looked at from a legal point of view only. We thought it would go to litigation and the record was taken to corporate. No one wanted to document on it." EMP 1 confirmed there was no formal peer review documented or any root cause analysis completed.