HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt #1) patients'/patient representatives' complaint/grievances reviewed, the Hospital failed to ensure that a verbal complaint was promtly reviewed, resolved, and documented.

Findings include:

1. On 1/10/2022, the Hospital's policy titled, "Patient Complaint and Grievance Management" effective 8/7/2020 was reviewed. The policy required, "V. Procedure/Responsibility...C. Each complaint is addressed, and an attempt made to resolve the issue(s) by staff working directly with the patient, regardless of the level at which the concern is initially reported. Any individual who initially reported. Any individual who initially hears about a complaint/grievance that cannot be immediately solved at the bedside is responsible for reporting the complaint/grievance to the appropriate process within their hospital...Documentation of Patient Complaints and Grievances...1. Record of Patient Complaints/Grievances are kept in a centralized location...that is managed by the Patient Relations Department...2. It is the responsibility of 'staff Present' receiving a patient complaint/grievance to address the reported issues immediately or to the best of their ability, report the situation to the appropriate manager, and follow unique regional process...3. It is the responsibility of the designated clinical leader or manager of the involved department to record actions taken in follow up to the submitted complaint/grievance."

2. On 1/10/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 11/22/2021, with the diagnoses of spinal stenosis (spinal narrowing), and lumbar adjacent segment with spondylolisthesis (spinal disorder). Pt. #1 had a planned lumbar decompression on 11/22/2021. Pt. #1 was discharged to a rehabilitation facility on 11/26/2021.

3. On 1/10/2022 at 11:54 AM, an interview was conducted with a Registered Nurse (E #2). E #2 stated that she recalls Pt. #1 and daughter who complained a lot. E #2 stated that she recalls Pt. #1's daughter complaining that Pt. #1 was restrained too hard, causing bruising during blood draws. E #2 stated that she reported the complaints from Pt. #1's daughter to the Nurse Manager (E #1).

4. On 1/10/2022 at 12:29 PM, an interview was conducted with E #1. E #1 stated that she was not aware of any complaints of bruising related to blood draws while Pt. #1 was in the Hospital. E #1 stated that it was not until after Pt. #1 was discharged did she learn about the bruises. E #1 stated that if a patient/patient representative has a complaint or grievance, they should be informed that they can file a complaint with the patient relations department.

5. On 1/10/2022 at 2:15 PM, a telephone interview was conducted with the Charge Nurse of 10 South East (E #5). E #5 stated that Pt. #1's daughter was frustrated that Pt. #1 had bruises and was concerned that Pt. #1 would develop more bruises if she (Pt. #1's daughter) could not stay overnight with Pt. #1. E #5 stated that Pt. #1's daughter complained that staff were holding Pt. #1 down for blood draws. E #5 stated that she explained to Pt. #1's daughter that the staff were only holding Pt. #1's hand and that blood draws may cause bruises. E #5 stated that she escalated Pt. #1's complaint to the Hospital Operations Administrator (E #6).

6. On 1/10/2022 at 4:07 PM, a telephone interview was conducted with a Hospital Operations Administrator (E #6). E #6 stated that she recalls meeting with Pt. #1's daughter to discuss the concern that Pt. #1's daughter could not stay overnight with Pt. #1. E #6 stated that Pt. #1's daughter also expressed concerns about the staff not being able to provide care for Pt. #1. E #6 stated that she does not recall having a conversation with Pt. #1's daughter about bruising or staff holding Pt. #1 too hard during blood draws. E #6 stated Pt. #1 was moved to a room closer to the nursing station as a solution to Pt. #1's daughters concerns. E #6 stated that she (E #6) followed-up with an email to the Nurse Manager (E#1).

7. The Hospital could not provide documentation of the review and resolution to Pt. #1's daughter's complaint related to Pt. #1 being held too hard during blood draws.