HospitalInspections.org

Based on review of facility's grievance log, policy and procedure and staff interviews the facility staff failed to implement their grievance process. [Patient #21]

The findings include:

Review of the facility's "Grievance Log" did not contain documentation related to Patient #21 or Patient #21's family.

Review of the facility's policy titled "Grievance, Patient" read "To provide patients and/or their legally authorized representative with the mechanism for submitting a grievance and a process for prompt resolution ... When a grievance is identified, based on the definitions outlined in this policy, a subcommittee of at least two Quality Executive Committee Members and any additional individuals that can contribute to the grievance resolution will meet to initiate investigation, determine resolution, and provide an appropriate response to the patient or legally authorized representative ... Definitions: Patient Grievance: A written (including e-mail or fax) or verbal complaint (when the verbal complaint about patient care that is unable to be resolved at the time of the complaint by the staff present) by a patient or their representative, regarding the patient's care...."

An interview was conducted on 03/07/2011 at 5:13 p.m. with Staff #2, the Chief of Operating Officer. Staff #2 reported the facility monitored grievances and concerns both positive and negative received through satisfaction surveys sent to patients post treatment. Staff #2 reported patient satisfaction concerns were discussed with department managers.

An interview was conducted on 03/08/2011 at 2:48 p.m. with Staff #1, the Vice President of Nursing and Staff # 5 the Emergency Department [ED] Manager. Staff #1 reported whenever a "verbal complaint" was presented the information was given to the "manager of the department involved to investigate." Staff #1 stated "Depending on the findings it would be handled in the department or sent to administration. If it's handled in the department the manager responds to the family sometimes by phone call or letter." Staff #5 stated "If I receive a concern from administration that someone has complained. I make a phone call, I usually document time and date, sometimes a summary of the conversation if it does not go well. Then I send that to the VP (Vice President) of Nursing. I may not document at all if it appears all went well."

An interview and review of the facility's Grievance log was conducted on 03/09/2011 at 7:18 a.m. with Staff #1. Staff #1 stated the events surrounding Patient #21 and the family's verbal complaint had not been processed as a grievance. Staff #1 reported Patient #21's son had contacted administration on 11/10/10 to report concerns related to the care Patient #21 received in the ED. Staff #1 reported Patient #21's son verbalized concerns the patient had experienced "active rectal bleeding and (family) having to call 911" from the ED waiting room's bathroom "to get help" for Patient #21. Staff #1 stated "He wanted to talk to the CEO (Chief Executive Office) not me. He wanted me to give him the names of the staff involved in his mother's care." Staff #1 reported that Patient #21's son had requested the names of the employees in order for Patient #21's daughter to pursue other actions. Staff #1 reported the information was given to the ED manager to investigate and The ED Manager had interviewed the ED nurse responsible for Patient #21's care on 11/09/10. Staff #1 stated "I call [the name of Patient #21's son] apologized and I felt he was satisfied. I did not perceive this as a grievance."

An interview was conducted on 03/09/2011 at 7:52 a.m. with Staff #5, Staff #2 and Staff #1. Staff #5 stated, "I only interviewed [the name of Staff #13, the Registered Nurse responsible for Patient #21's ED care]. She was the only one I talked to." Staff #5 reported she did not document the interview with Staff #13. Staff #1 stated, "We did not document because we felt this was a complaint not a grievance. We handled this as a complaint because it was verbal. We thought he had been satisfied, because he wanted the CEO to know what was going on and he talked to the CEO." The surveyor presented Staff #1 with the information the facility had offered, related to Patient #5's family had gathered the names of staff that had provided care "to pursue other actions" and whether that indicated the family's concern had not been resolved and should have changed the "verbal complaint" to a grievance. Staff #2 stated, "I talked to [the name of the CEO] last night. We feel this was not in witting; it was not an e-mail. [Name of Patient #21's son] had a conversation with [Name of the CEO]. [Name of the CEO] felt like it was a complaint and that we had dealt with the concerns... [Name of the CEO] had verbally spoken with the family and the family was satisfied therefore it was not a grievance." Staff #1 acknowledged the family pursued their concerns by filing a complaint with the State regulatory agency. Staff #2 acknowledged the family had stated to the facility a complaint "might be filed with the State regulatory agency."

Based on review of policy/procedure, medical record review, and staff interview the facility failed to reassess two of two patients triaged as in need of urgent care. (Patient #20 and #21)

The findings include:

Review of the facility's policy titled "Triage of the Emergency Department Patient. Statement of Purpose: The Standard of Care for Triage [the name of the facility] states that all patients will be triaged by a Registered Nurse upon their arrival to the Emergency Department. Patients will receive a nursing assessment, prioritization of care and appropriate initial emergency care as indicated, in order to be seen by the Emergency Department Physician as soon as possible ... Upon the completion of the Triage Assessment, the Registered Nurse will assign a triage level classification to the patient based on the triage assessment. Triage levels are classified as:
? Level I: Emergent- Patients with critical life threatening injuries or illnesses who require immediate intervention ...
? Level II: Urgent-Patients with major injuries or illnesses which require intervention within 20 minutes to 2 hours. Patients evaluated as urgent during the triage assessment may be registered and asked to wait in the Emergency Department waiting area ...
? Level III: Non-Urgent- Patients with minor injuries or illnesses....
Patients in the Emergency Department waiting area will be reassessed according to their acuity as follows: Urgent (Level II) Every 60 minutes with checks for changes in patient condition and vital signs every 2 hours ..."

Review of Patient #20's medical record revealed the patient was a 65 year old, who sought treatment on 11/09/2010 at the facility's Emergency Department (ED) for rectal bleeding. Patient #20's medical record documented the patient had been triaged at "1851 (6:51 p.m.)" and given a "Level II" - urgent care status. The facility staff documented the time that Patient #20 had been brought into a ED treatment room as "1955 (7:55 p.m.)" 63 minutes after having been triaged. Review of Patient #20's ED record did not reveal documentation the patient had been reassessed during the 63 minutes within the ED waiting area.

Review of Patient #21's medical record revealed the patient was a 78 year old, who sought treatment on 11/09/2010 at the facility's Emergency Department (ED) for rectal bleeding. Patient #21's medical record documented the patient had been triaged at "2004 (8:04 p.m.)" and given a "Level II" urgent care status. The facility staff documented the time which Patient #21 had been brought into a ED treatment room as "2107 (9:07 p.m.)" after the patient's family called 911 while in the ED waiting room's bathroom. Review of Patient #21's ED record did not reveal documentation the patient had been reassessed during the 63 minutes within the ED waiting area.

An interview was conducted on 03/08/2011 at 4:07 p.m. with Staff #13, the Registered Nurse that had triaged Patients #20 and #21. The interview was conducted in the presence of Staff #1, the Vice President of Nursing. Staff #13 reviewed the medical records for both patients and reported the patients' vital signs had been stable and the ED was full. When asked if she had performed the reassessment for Patients #20 and #21 in accord with the facility's policy/procedure for triaged patients placed in the ED waiting area; Staff #13 stated, "We were busy and I might have scanned (visibly) the waiting area." When asked if she had documented visibly scanning the patients in the ED waiting area; Staff #13 reviewed the medical records and stated "No." Staff #13 stated, "When we get busy like it was that night we all cover for each other, someone else might have scanned the waiting area, but it's not charted."

An interview was conducted on 03/08/2011 at 4:33 p.m. with Staff #12, a Patient Registrar. Staff #12 reported part of the duties the Registrar was to notify ED staff if patients reported changes in condition or if the Registrar personnel observe changes in the patient's condition. When asked if the Registrar personnel received training in what to observe; Staff #12 stated, "No, after a while you can tell if their condition has changed and you call the nurses in the ED." When asked if Patient #21or her family had approached the Registration window to report a change in the patient's condition; Staff #12 stated "Yes." Staff #12 reported the ED had been very busy that evening and they (the registration staff) "felt stuck in the middle" between the request of the patients and the ED nursing staff. Staff #12 stated "I called back to the nurse's station each time [Patient #21 ' s name] or her family came to the desk to report a change. The nurses kept saying we're full tell them they have to wait. None of the nurses came out. I felt sorry for the family but there was nothing I could do." Staff #12 stated, "[Patient #21 ' s name]'s daughter was so upset she said she would call 911 and then when no one came she called 911; then the nurse came." When asked if there was a place to document each patient contact and call to the ED nursing station; Staff #12 stated "No. We only have space to document their name, complaint, when the patient's arrive, when the nurse gets the patient for triage and when they are placed in a treatment room."


An interview was conducted on 03/09/2011 at 7:07 a.m. with Staff #1. Staff #1 reported the ED nursing staff may have performed their observations of patients within the ED waiting area, but had failed to document their assessments. Staff #1 reported the medical records reviewed failed to have documentation the facility's policy/procedures for triage had been followed and that patients deemed in need of urgent care had not been reassessed by qualified staff within the required timeframe.