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Based on record review and interview, the facility's representatives failed to comply with the facility's clearly defined procedure for submission of a patient's written or verbal grievance/complaints concerning the quality of care and discrimination, in that,

Patient #1 complained to a care giver (Personnel #11) on 2/11/2022 and the care giver did not document the complaint/grievance for review and investigation by the facility.

Findings

There was no quality of care and discrimination complaint/grievance documented for 2/11/2022.

The documented interview of Personnel #11 by Personnel #6 during an investigation reflected, "(Personnel #11) remembers this patient very well...pt (patient) was upset about very many things and his care at THF. Per (Personnel #11) by the time she had an encounter with pt, he was already upset. (Personnel #11) denies any allegation about patient being treated unfairly due to race."

During an interview on 12/19/2023 ending at 1:19 PM, They were asked about the interview that reflected (Personnel #11's) knowledge of the patient complaints and if (Personnel #11) documented the grievance. Personnel #1 stated no. Personnel #1 was asked if a complaint should have been documented. Personnel #1 stated yes.

The 12/12/2023 last reviewed "Patient Grievance Resolution" required, "The hospital is committed to responding to needs, concerns, and grievances of patients, family members, visitors or legal representatives promptly as possible. Hospital staff should alert appropriate staff and/or leadership concerning any patient concern or grievance as soon as possible and utilize the chain of command when unable to resolve in a timely manner..."

The 11/11/2020 last reviewed "Patient Rights and Responsibilities" required, "that the protection and support of the basic human rights of freedom of expression, decision and action are important to the healing and well-being of our patients. Therefore, we strive to treat patients with respect and with full recognition of human dignity. Decisions regarding healthcare treatment will not be based on race..."

Based on record review and interview, the hospital failed to ensure a physician discharge summary for 1 of 2 patients (Patient #1's 2/11/2022 discharge).

Findings

Patient #1 had no physician discharge summary for the 2/11/2022 discharge.

During record review and interview on 12/19/2023 at 10:00 AM, Personnel #1 and #2 were present. Personnel #2 navigated the records and confirmed the findings. The attending physician did not see the patient on they day of discharge. A covering physician documented a progress note, but no discharge summary. There was no discharge summary found for the 2/11/2022 discharge. They were asked if the investigation found that there was no discharge summary. Personnel #1 stated no. They were asked if a Discharge Summary is required. Personnel #1 stated yes. In our bylaws. Personnel #1 was asked for the bylaws. Personnel #1 provided the bylaw requirement.

The facility's 3/29/2021 revised "Medical Staff Bylaws" required, "The content of the discharge summary shall contain the reason for Hospitalization, significant findings, instructions to the patient and family, as appropriate, be sufficient to justify the diagnosis and treatment, include follow-up instructions and shall state the condition of the patient, outcome of the hospitalization, disposition of care, final diagnosis, complications and procedures performed at the time of discharge..."