HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure that a process for the resolution of patient complaints was implemented per hospital policy and regulatory requirements. This resulted in inaccurate/incomplete reporting of patient complaints to hospital leadership, as well as a lack of follow-up with patients or their legal representatives/family. In addition, systemic issues regarding hospital patient care had the potential of remaining unidentified and unaddressed because there was no data collection or trending of data regarding complaints occurring.

Findings were:

Review of facility policy amd procedure Patient Complaints/Grievances last reviewed 4/7/2021 reflected:
"IV. POLICY:
The patient shall have the ability to file a complaint or grievance as part of the patient rights process and in compliance with the Medicare COP and Joint Commission Standards. Patients registering complaints and/or grievances shall not be subjected to retaliation and/or barriers to service. The Hospital's process for managing complaints and grievances must incorporate the following objectives: ...
C. Provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by patients and/or patient representatives.
D. Provide an on-going system for monitoring and trending patient complaints and grievances...

6. The Patient Safety Officer will maintain a log that provides response to the patient ...The Hospital's Quality Management department will incorporate grievances into the complaint/grievance data set, which will be aggregated, analyzed and reported quarterly to the designated Grievance Committee, Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Committee, MEC (Medical Executive Committee), and the Governing Board ..."

During an interview with the CNO and Quality Manager, the CNO stated that complaints are resolved at bedside if able and service recovery is performed to attempt a positive outcome, therefore complaints do not rise to the level of grievances. If the issue is perceived to be resolved with service recovery, then there is no documentation of the complaint to follow up on. The CNO stated that complaints that are resolved at bedside have not been a part of the grievance log and are not logged or trended currently.

The facility was unable to provide any documentation or log of complaints. The facility could not provide documentation on how complaints are trended and reviewed by the QAPI committee as per facility policy.