HospitalInspections.org

Based on document reviews, and staff interviews, it was determined the facility failed to follow Policies for responding to Patient Grievances in the Emergency Department (ED) by not meeting the thirty (30) day deadline and not sending the complainant a letter requesting more time in thirteen (13) out of sixteen (16) ED Grievances reviewed. This failure has the potential to negatively impact all Patients filed a complaint of grievance with the facility.

Findings include:

A review was conducted of the policy titled, "Patient Complaints And Grievances," last revised 8/14/2023. The policy states in part, "...Once a grievance has been filed, a Patient Advocate, or designee, will respond to the complainant in writing, within seven (7) calendar days. This written response shall, at a minimum, acknowledge The patient's concerns. If the resolution will take longer than seven (7) days, the acknowledgment letter will inform the patient or the patient ' s representative that the hospital is still working to resolve the grievance and include the current progress and the time frame for future updates. [Health System] strives to resolve all grievances as soon as possible...Grievances should be resolved in thirty (30) days or less. If resolution of a grievance will take longer than thirty (30) days, the complainant will be notified of the delay. Upon resolution, a written response will be sent to the complainant..."

A review was conducted of the facility's "Origami" (Electronic Event Reporting System) event report for complaints and grievances for the past three (3) months. Several grievances were reported as still open beyond the thirty (30) day window. The log states the following:

Event Ref #24-007303 Date of Discovery 08/12/24
Event Ref #24-007293 Date of Discovery 08/12/24
Event Ref #24-006741 Date of Discovery 08/07/24
Event Ref #24-007918 Date of Discovery 08/16/24
Event Ref #24-007279 Date of Discovery 08/12/24
Event Ref #24-007001 Date of Discovery 08/09/24
Event Ref #24-007920 Date of Discovery 08/16/24
Event Ref #24-006013 Date of Discovery 08/01/24
Event Ref #24-004703 Date of Discovery 07/21/24
Event Ref #24-005211 Date of Discovery 07/25/24
Event Ref #24-007585 Date of Discovery 08/14/24
Event Ref #24-008505 Date of Discovery 08/21/24
Event Ref #24-008491 Date of Discovery 08/21/24

Staff #12 confirmed via email to Staff #11, on 09/25/24, at 1:31 p.m. the following details regarding the above Grievances:
The following Grievances "No extension letter sent.":

Event Ref #24-007303 Date of Discovery 08/12/24
Event Ref #24-007293 Date of Discovery 08/12/24
Event Ref #24-006741 Date of Discovery 08/07/24
Event Ref #24-007918 Date of Discovery 08/16/24
Event Ref #24-007279 Date of Discovery 08/12/24
Event Ref #24-007001 Date of Discovery 08/09/24
Event Ref #24-007920 Date of Discovery 08/16/24
Event Ref #24-006013 Date of Discovery 08/01/24
Event Ref #24-004703 Date of Discovery 07/21/24
Event Ref #24-005211 Date of Discovery 07/25/24
Event Ref #24-007585 Date of Discovery 08/14/24
Event Ref #24-008505 Date of Discovery 08/21/24
Event Ref #24-008491 Date of Discovery 08/21/24


Staff #11 confirmed on 09/25/24, at approximately 2:00 p.m., the email was accurate per Staff #12. Thirteen (13) out of sixteen (16) ED Grievances filed greater than thirty (30) days ago, had no extension letter sent to the complainant explaining more time was needed for the facility investigation.

A telephone interview was conducted with Staff #5 and Staff #10 on 09/24/24, at 3:22 p.m. Regarding the incident with Patient #1, Staff #5 states in part, "I was not aware that the patient's family filed a complaint or grievance ...And again, I did not know the family had made a complaint, so I had not done an investigation into the complaint."

A telephone interview was conducted with Staff #8 on 09/25/24, at 2:30 p.m. Regarding training for Staff #5 to complete grievance investigations, Staff #8 states, "In person training was conducted with [Staff #5 and Staff #10] on 07/01/24, on the system and responding to and accessing grievances. Only one person can be assigned to receive the grievances, but other designated staff in the department can access them. If anyone has a problem responding to grievances in a timely manner, they can reach out to the patient advocate team and request an extension so we can keep the complainant updated. [Staff #5] did not reach out to us with any concerns in being able to respond. We had gotten a new system for inputting complaints and grievances in June, and we found after getting the new system that the previous grievances in the old system had been closed out even if they weren't completed and had been playing catch up ever since. We normally track how many letters are overdue, but the last reported to Quality was in April and at that time, the last reporting from February was zero (0) letters overdue."

An additional telephone interview was conducted with Staff #5 on 09/25/24, at 9:20 a.m. Regarding the grievance filed on behalf of Patient #1, Staff #5 states in part, "The Patient Advocates usually send me a notification, so I am aware of a complaint. I am aware that I am behind more than thirty (30) days on a lot of complaints. I try to pull up ones that seem critical and respond, but I am behind. I've been in this position for about a year, and I don't have a lot of help under me. The director of the ED does not have access to the complaints and grievances, so they cannot help. I'm the only one that can investigate the complaints and grievances. The director would help me if [he/she] could, but [he/she] does not have access ..."

An interview was conducted with Staff #9 on 09/25/24, at 3:14 p.m. Regarding the incident involving Patient #1, Staff #9 states in part, "I'm aware of the problem with the new Origami (Event Reporting System) system with addressing complaints. We get a lot of complaints in the emergency department, and I'm not surprised it's taking longer than normal with the number of complaints we get."