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Based on review of facility policy, facility documentation, and staff (EMP) interview, it was determined that the facility failed to ensure that the policy and complaint resolution process had the hospital's own employees resolving and responding to complaints and failed to ensure the final written notice of the hospital's investigation, decision and date of completion was provided to the complainant and/or updates to the complainant within the timelines of the facility policy in two of two grievances reviewed (OTH1 and OTH2).

Findings include:

Review on March 26-27, 2019, of the facility's "Patient Complaint/Grievance" policy, last reviewed by facility October 2018, revealed "Policy: In supporting the rights of our patients, it may be necessary to reconcile the needs and desires of all patients regarding their care... Therefore, the... Hospital Administration has prescribed a mechanism for reviewing, evaluating and resolving issues that may arise. 1. When the physician iof" (sic) "record is notified of a conflict by the patient, family member or Hospital staff involving the care of a patient, the physician should attempt to resolve the problem. If needed, the physician may call upon available resources such as TCH" (Troy Community Hospital) "Patient Advocate/Social Worker and/or Nurse Manager for assistance. During non-business hours, the [name of health system] "Risk Management Department and/or TCH Patient Advocate/ Social Worker. Depending on the nature of the issue, the physician may consult with the patient advocate, who in turn may consult with the risk manager, Ethics Advisory Committee and/or others as appropriate. Preferably such conflicts should be resolved at the patient, physician, and staff level. Howver" (sic) "in instances when this is not possible, final resolution rests with the Patient Advocate/Social Worker. 2. To deal effectively with patient and family concerns/complaints while contributing to increased satisfaction and quality of care, Service Recovery is the responsibility of all employees. 3. In addition, patients and family members may bring complaints/grievances directly to the GHS Risk Management Department or the individual(s) considered most appropriate. a. Complaints pertaining to non-medical aspects of care (i.e. housekeeping, food service and billing concerns) shall be assessed and answered by the Patient Advocate/Social Worker or referred to the appropriate department for resolution and would not usually be considered a grievance and would therefore not require a written response. b. Complaints/grievances regarding medical aspects of vcare" (sic) " of physicians shall be assessed and answered after comsultation" (sic) "with the Department Director, Chief of Medical Staff, or Hospital Administrator as appropriate. In general, Risk Management will develop a response using information from this review. c. Complaints/ grievances pertaining to the treatment or mistreatment of a patient may be communicated to the patient advocate accompanied by documentation relevant to responding to the complaint as deemed appropriate... e. Patient complaints/grievances shall be monitored by the Risk Management Department to detect deficiency trends, patient relationship problems, and/or unresponsiveness to the needs and concerns of patients. The Hospital Patient Advocate/ Social Worker will provide a quarterly report to administratin" (sic) " and Performance Improvement Executuve" (sic) "Council summarizing patient complaint/grievance activity. 4... a. All written grievances will be acknowledged within five (5) business days by letter or telephone call. A written response will be sent within 30 days from date of receipt of grievance. In those instances where a final resolution has not been achieved in 30 days, the patient will be kept apprised of any progress in the investigation. All written responses shall include: (1) name of Hospital contact person; (2) steps taken by Hospital, department, or area of service to investigate the grievance; (3) results of the investigation; and (4) date of resolution. b. All verbal complaints will be addressed using the same time frame of 30 days for final resolution. Information gained from investigation will be presented, either verbally or in writing to the patient..."

Review on March 26, 2019, at 1:10 PM, of the facility's complaint log and selected two complaints/grievances for review (OTH1 and OTH2).

Further review on March 27, 2019, at 9:40 AM of the complaints/grievances with EMP1 and EMP2, revealed the following:

OTH1 was a concern received by the facility on January 25, 2019. The concern was related to quality of care by the provider with an outpatient visit in which the patient felt the provider did not address the patient's concerns for the outpatient visit. An acknowledgment letter was sent to the complainant on February 7, 2019. As of March 27, 2019, at the time of review, there was no additional documentation related to a final response letter to the complainant or documentation of complainant update of status.

OTH2 was a concern that outlined multiple quality of care issues and named specific staff that the complainant felt did not meet the patient's needs. The concern was from a family member of the patient, who did not have legal guardianship or power of attorney. The concern was received by the facility on February 12, 2019. The facility was unable to obtain patient consent to respond to the family member regarding the concerns until February 28, 2019. An acknowledgement letter was sent to the complainant on February 28, 2019. The acknowledgement letter was signed by a person who was not an employee of the hospital and title showed the person was from a sister clinic of the hospital. As of March 27, 2019, there was no documentation of a final response letter to the complainant or documentation of complainant update of status.

Interview with EMP2 on March 27, 2019, at 10:00 AM confirmed there was no documented updates in the facility's complaint log. EMP2 stated EMP2 would check with the departments related to updates.

Interview with EMP8 on March 27, 2019, at 10:45 AM related that EMP8 missed the concern related to the complaint (OTH1) in their inbox. EMP8 stated they had reviewed the concern and spoke with the patient related to concern on the telephone today, March 27, 2019.

Further interview with EMP2 on March 27, 2019, at 12:20 PM, named a person who was not an employee of Troy Community Hospital, as handling the complaint related to OTH2. The named person was employed at a sister clinic in their health system. EMP2 stated that this person had reported to EMP2 that they spoke with the complainant via telephone on March 21, 2019.