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Based on document review, interview, and policy review the facility failed to log (50 of 50) grievances received concerning cleanliness of patient care areas from post-hospitalization follow-up with patients resulting in denying 50 of 50 patients to file a formal grievance. Findings include:

On 8/30/2021 at 1340 a review occurred of the facility's complaint and grievance log from 2/1/2021 through 8/30/2021. During review of the complaint and grievance log it was noted complaints/grievances concerning environment were not included. On 8/30/2021 at 1400 an interview occurred with the Director Accreditation and Employee Health, Staff A. Staff A was queried if further documentation could be provided for complaints/grievances related to environment or physical plant facilities. Staff A stated, "We will arrange an interview with Staff I, the Patient Experience Administrator.

On 8/31/2021 at 0915 an interview occurred with Staff I, the Patient Experience Administrator. Staff I was queried if any complaints/grievances were received by the Patient Experience department in relation to environment, cleanliness, or physical environment. Staff I explained that when patients were called for follow-up after the patient's stay that any comments received were forwarded to the appropriate departments. Staff I was then asked if a log of grievances was kept from the follow-up calls. Staff I stated, "No...we do keep track of the number of complaints specific to each unit." Staff I was asked to provide documentation of how many complaints were received concerning cleanliness, environment, or physical plant in patient care areas." Staff I was queried how those comments received as part of the post hospitalization follow-up were investigated. Staff I stated the comments/concerns were handled by the department receiving notice of those concerns but that no follow-up was conducted with patients.

On 8/31/2021 at 1130 a document review occurred of the policy titled, "Grievance and Complaint Management," with a revision date of 7/28/2021. According to the policy it states, "Post-hospital verbal communications regarding patient care that would routinely have been handled by
"caregivers present" if the communication had occurred during the stay/visit are not required to be defined as a grievance, however, it is Sparrow ' s practice to investigate these as a grievance."