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Based on record review and interview, the Hospital failed to ensure a grievance regarding the care for one Patient (#1) was provided a written response out of a total sample of 10 Patients.

Findings include:

Review of CMS regulation 482.13(a)(2)(iii) indicated the following:
-In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

The Hospital policy titled "Patient Complaint and Grievance Policy", revised 12/16/22, indicated the following:
-Patients and their family members may file a complaint or grievance verbally or in writing regarding a concern about quality of care, treatment, or services, or human rights violations.
-The Hospital will respond in accordance with state and federal regulations, to respond promptly and thoroughly to any patient complaint or grievance made against the Hospital, its employees, or members of its medical staff.
-Complaints and grievances are investigated, and the steps of the investigation, conclusions, recommendations, and actions related to the investigation are documented in the electronic reporting system and the results are shared with the patient and, when appropriate, the complainant.

Patient #1 was admitted to the Hospital on 12/31/21 with COVID-19 pneumonia, Chronic Obstructive Pulmonary Disease, shortness of breath, dyspnea (difficulty breathing), thrombocytopenia, and acute kidney failure.

Review of Patient #1's medical record indicated Patient #1 had been admitted inpatient to the Hospital from the Emergency Department. Patient #1 required high-flow oxygen at 15 L (Liters) during his/her time in the Hospital to maintain adequate oxygen levels. Patient #1 was transitioned to BIPAP (non-invasive ventilation) to maintain his/her respiratory status. On 1/16/22, Patient #1 removed his/her own BIPAP, a rapid response was initiated, and the Patient was transferred to the Intensive Care Unit (ICU). The Patient chose to have his/her code status as Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Patient #1 expired on 1/17/22 prior to the scheduled meeting to discuss the Patient's plan of care with him/her and his/her family.

The Hospital provided the Surveyor with a copy of a written grievance received in June 2022 from the Spouse/HCP (Health Care Proxy) of Patient #1. The written complaint indicated concerns regarding the treatment plan for Patient #1, the visitation restrictions for Patients in the Hospital related to COVID-19 outbreaks, and not being able to be with Patient #1 during his/her passing. The Hospital also provided the Surveyor with evidence the Chief Medical Officer (CMO) had reviewed the grievance regarding Patient #1 and the Patient's medical record.

The Hospital failed to provide the Surveyor with any evidence of a written response to the Spouse/HCP of Patient #1, nor any evidence of correspondence with the Hospital's Patient Advocate.

During an interview on 1/31/23 at 2:00 P.M., the Director of Risk Management said a written response to the grievance regarding Patient #1 was not sent to the Patient's Spouse/HCP. She also said the grievance never reached the Patient Advocate for the Hospital. She said the Hospital would normally provide a written response to a grievance regarding a patient.