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Based on record reviews, interviews, and review of the hospital's grievance policies and procedures, the hospital failed to ensure its grievance policies and procedures were followed for 1 of 1 complaint received. (Patient 13)

The findings are:

Hospital policy and procedure, titled, "Patient Grievances", reads, " ....12. The Board of Trustees (the Board) has delegated the responsibility for review and response to patient grievances to Administration. 13. Administration will investigate all patient grievances and may include staff from departments responsible for performance improvement, guest services, corporate compliance, and best practices as needed. 14. If the grievance has not been resolved or the investigation is not completed within 7-10 days of receiving the patient grievance, LMC shall notify the patient or the patient's representative via written communication that the hospital will follow up with a written response within 45 days. 15. The written response shall advise the patient of steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in a manner the patient can understand."

Cross Reference to A 0123: The hospital failed to follow its own policies and procedures for management of patient grievances in that the hospital had no formal documentation of contact or resolution of Patient 13's grievance received by the Chief Executive Officer and forwrded by Executive Assistant 1 on March 15, 2019 to the Director of Nursing. There was no formal written communication to the patient for follow yp or resolution of the patient's grievance.

Based on record reviews, interviews, and review of the hospital's grievance policies and procedures, the hospital failed to ensure its grievance policies and procedures were followed for 1 of 1 complaint received. (Patient 13)

The findings are:

Hospital policy and procedure, titled, "Patient Grievances", reads, " ....12. The Board of Trustees (the Board) has delegated the responsibility for review and response to patient grievances to Administration. 13. Administration will investigate all patient grievances and may include staff from departments responsible for performance improvement, guest services, corporate compliance, and best practices as needed. 14. If the grievance has not been resolved or the investigation is not completed within 7-10 days of receiving the patient grievance, LMC shall notify the patient or the patient's representative via written communication that the hospital will follow up with a written response within 45 days. 15. The written response shall advise the patient of steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in a manner the patient can understand."

Cross Reference to A 0123: The hospital failed to follow its policies and procedures for management of patient grievances in that the hospital had no formal documentation of contact or resolution of the Patient 13's grievance received by the Chief Executive Officer in March 2019. The only documentation of the grievance was a chain of emails from March 15, 2019 through May 2019. There was no documentation of written responses to the patient or of resolution of the patient's grievance.

Based on record reviews, interviews, and review of the hospital's grievance policies and procedures, the hospital failed to ensure its grievance policies and procedures were followed for 1 of 1 complaint received. (Patient 13)

The findings are:

Hospital policy and procedure, titled, "Patient Grievances", reads, " ....12. The Board of Trustees (the Board) has delegated the responsibility for review and response to patient grievances to Administration. 13. Administration will investigate all patient grievances and may include staff from departments responsible for performance improvement, guest services, corporate compliance, and best practices as needed. 14. If the grievance has not been resolved or the investigation is not completed within 7-10 days of receiving the patient grievance, LMC shall notify the patient or the patient's representative via written communication that the hospital will follow up with a written response within 45 days. 15. The written response shall advise the patient of steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in a manner the patient can understand."

Review of Patient 13's chart revealed the patient was admitted to the hospital for an abdominal hysterectomy on 01/29/2019 at 09:01 AM. During the course of the complaint survey, the hospital's grievance data was reviewed, and Patient 13 was not listed on the patient grievance log although the patient sent a letter post discharge in March 15, 2019 to the Chief Executive Officer (CEO) with concerns about the patient's previous hospitalization in January 2019. Review of the hospital's correspondence related to the patient's complaint revealed the Executive Assistant 1 requested the Director of Nursing to review the patient's complaint. The initial email from Executive Assistant 1 dated 3/15/2019 referred the patient's grievances to the Director of Nursing. On 04/09/2019, the email trail showed an email dated 04/09/2019 at 3:31 PM from Executive Assistant 1 requesting an update from the DON related to the patient's grievance. An email dated 04/09/2019 at 6:26 PM from the Chief Nursing Officer to the Director of Nursing stating the Chief Nursing Officer was going to have a meeting to discuss what the reviews revealed and decide what the next steps would be. The last email dated 5/21/2019 at 5:35 PM from the Director of Nursing revealed "I did follow up with the patient a few weeks ago. She was happy to talk with someone and was satisfied with the call."

A face to face interview with Vice President (VP) 1 on 6/25/19 at 3:00 p.m., the VP revealed the Chief Executive Officer had received a complaint letter from the patient. The complaint was given to the Chief Nursing Officer who then gave the complaint to the Director of Nursing (DON) for follow up with the complainant.

On 6/25/19 at 10:12 a.m., a face to face interview with Director 1 revealed, "When we get a complaint, it is reviewed, and we consider it. We write a letter within seven days. We meet to decide what to do. It usually involves guest services, risk management, department or clinical staff who review the circumstances. We make decisions of outcomes and write another letter." When asked how a patient files a complaint, Director 1 stated, "We see 99%(percent) of all patients and they receive an Action Line Card that has a number that rings in my office."

The hospital failed to follow its policies and procedures for management of patient grievances in that the hospital had no formal documentation of contact or resolution of the patient's grievance.