HospitalInspections.org

Based on record review and interview the facility failed to ensure that grievances involving patients were thoroughly investigated for complainant resolution in 1 of 3 (Patient #1) grievances reviewed and failed to follow facility policy regarding written resolution to the complainant in 1 of 3 (Patient #1) grievances reviewed.

Findings include:

The facility policy, titled, "Patient Complaint and Grievance Resolution Policy", dated 3/1/2021 revealed, under definitions "Emergency Grievance: Situations that may endanger the patient, such as alleged neglect, abuse, or unsafe patient care..." Under Grievances Investigation, Review and Timelines, "For emergency grievances, an expedited investigation will be conducted and the patient will be sent a written resolution to the complainant within five (5) business days from the date the grievance was filed..."

Review of Patient Experience Event (107838) submitted 4/1/2021 revealed an allegation of neglect to a patient. The complainant alleged that the patient was transferred to their facility with an infestation of lice and neglect of his personal hygiene. The section titled "Resolution" revealed, "Infection prevention reviewed and provided feedback on policy. Manager reviewed and signed off. File closed."

The Patient Experience Event does not reveal any actions to determine if the allegation was founded. There was not a medical record review to confirm personal hygiene was provided, no interviews with staff or follow up education.

Review of the Patient Experience Event revealed the following, "They (the complainant) stated this is an infection control concern and would appreciate feedback on what is discovered with review." During an interview on 5/17/2021 at 3:40 PM with Director of Patient Experience J, Director of Patient Experience J confirmed that there was no follow up or resolution letter sent to the complainant.

During an interview on 5/17/2021 at 3:55 PM with Manager D when asked about his investigation into the grievance, Manager D stated that he thought that the Infection Preventionist had taken care of it and there was nothing else for him to do. The Patient Experience Event follow up note from the Infection Preventionist stated, "...I've attached the lice policy...please share with staff...I will leave that to (Manager D) and his team for follow up and more thorough evaluation. Manager D stated that he did not do any further investigation or share the lice policy with staff.