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Based on interview and record review it was determined the facility failed to follow their own policy for the prompt resolution of patient complaints/grievances for one (1) of ten (10) sampled patients (Patient #1) when the patient complained that the sleep lab had bed bugs. The facility made contact with Patient #1 by phone and, according to Patient #1, argued that the sleep lab did not have bed bugs. The complaint was documented on an incident report; however, the facility failed to follow their own policy for customer grievances and failed to provide a written notice (response) to the complainant regarding steps taken to resolve the complaint.

The findings include:

Review of the facility policy titled "Grievance Policy," revised May 2015, revealed the facility had a process for the resolution of patient grievances. According to the policy, a patient grievance was a written, e-mailed, faxed, telephoned, or face-to-face concern provided about patient care by the patient and/or the patient's representative. The policy further stated all verbal or written complaints regarding hospital compliance with CMS requirements were considered a grievance and if the complaint received could not be resolved at the time of the complaint, it would require further action for resolution and the complaint was considered a grievance. The policy further stated all grievances would be followed up with a letter that identified the name of the hospital, contact person, steps taken on behalf of the patient and/or patient's representative to investigate, results of the grievance process, the date of completion, and verification that the patient and/or patient's representative was satisfied with the response.

Review of Patient #1's medical record revealed an order for a sleep study to be conducted on Patient #1 at the facility's sleep lab. According to the medical record the sleep study was conducted on 07/21/16. Patient #1 was diagnosed with Mild Obstructive Sleep Apnea.

Review of the facility's complaint log revealed the facility received a complaint from Patient #1's representative that stated Patient #1 reported having seen bed bugs at the sleep lab on 07/21/16. There was no evidence provided that verified the facility conducted an investigation and/or resolved Patient #1's complaint.

Interview with Patient #1 on 08/30/16 at 12:10 PM revealed the Director of the sleep lab called the patient regarding the complaint and accused Patient #1 of making a false statement. Patient #1 stated the Director argued and kept telling Patient #1 that the sleep lad did not have bed bugs. Patient #1 stated the Director was rude and did not believe the patient. Patient #1 stated the facility did not follow up with any written notice and did not provide the patient with any action taken to resolve the complaint.

Review of an incident report revealed that on 08/18/16 Patient #2 reported having seen bed bugs at the sleep lab and the patient's representative made a call to the facility with a complaint of bed bugs. The pest control contractor was called and bed bugs were identified at the sleep lab.

Interview with the Chief Nursing Officer on 08/30/16 at 9:00 AM confirmed staff failed to follow the facility protocol/grievance procedure when Patient #1's representative provided information that Patient #1 had complained of seeing bed bugs during a sleep lab procedure on 07/21/16.

Interview with the Attending Physician (who acted as the patient representative for Patient #1 and Patient #2) on 08/30/16 at 3:00 PM revealed he received two complaints regarding bed bugs at the facility sleep lab and both complaints were reported to the sleep lab Director. The Attending Physician stated Patient #1 reported seeing bed bugs during his/her visit on 07/21/16 and Patient #2 reported seeing bed bugs on 08/17/16 during a sleep study procedure.

Interview with the sleep lab Director on 08/30/16 at 9:30 AM revealed the Director failed to document Patient #1's grievance per facility protocol/regulations. The Director stated he thought the complaint was resolved when the pest control contractor did not find any bed bugs during their visit on 07/28/16. The sleep lab Director gave no explanation why the facility failed to follow up with a written notice to Patient #1 regarding the patient's complaint.