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Based on record review and interview the facility failed to acknowledge, provide resolution and notification outlined in the complaint/grievance policy for 1 grievance (Patient #1) in a total of 5 complaints/grievances reviewed.

A review of the facility's policy titled, "[Facility name] System complaint/Grievance Policy" last revised 08/2024 revealed, "... Definition of a Grievance ... a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care, abuse or neglect ... C. Grievance Process-Acknowledgment, Investigation and Resolution 1. B. The department manager/designee contacts the grievant via acknowledgment letter, telephone or in person (when applicable) to acknowledge the grievance and explain the grievance process. The grievant is advised of an expected follow-up date. The grievance is acknowledged by phone or in writing within seven (7) calendar days ... 2. Investigation (3rd paragraph) At the conclusion of the investigation, the department manager/designee sends a letter to the patient/patient representative/person acting on behalf of the patient describing the conclusions of the investigation and, when appropriate, the steps taken for resolution."

A review of the grievance written by ER (Emergency Room) Director F filed to the facility via telephone call on 03/18/2025 from Complainant A revealed, "[Complainant A] upset with fact that [Patient #1] was discharged from the ED (emergency department) and had to return after passing out at home due to blood loss and retained placenta." Review of the grievance revealed that Patient #1's medical record was reviewed and investigated on 03/20/2025 by ER Physician O who stated, "[Patient #1] was seen in ER 3/10 with ED Physician Assistant who noted stable vital signs, ordered ultrasound. Patient was then discussed with OBGYN (obstetrician and gynecologist) who came and saw patient. OB felt patient was stable for discharge or would have admitted for further workup ... ER care appropriate ..." Further review of the grievance revealed that the grievance was set to "resolved" and a letter was sent to Patient #1 on 03/24/2025 by ER Director F who stated in the grievance follow-up, "[Complainant A] called with initial complaint, attempted to contact [Patient #1], no answer x2. [Complainant A] not on HIPAA (Health Insurance Portability and Accountability Act) so inappropriate to send letter, contact letter sent to patient."

A review of Patient #1's HIPAA document titled, "[Facility name] Authorization to communicate Health and billing information to designated Persons" last updated 01/17/2018 by Patient #1, revealed that Patient #1 listed Complainant A and Patient #1's spouse on the list to " ...authorize [facility name] to verbally disclose protected health information ..." There was no evidence that Complainant A was contacted by ER Director F regarding the grievance, per facility policy.

During an interview on 07/08/2025 at 1:15 PM with Quality Improvement Coordinator Q, when asked about the HIPAA form, she stated that the form is indefinite until the patient changes it.

Based on record review and interview, facility staff failed to notifiy the physician and document a reassessment of vital signs in response to an acute change in medical condition for 1 of 1 patients (Patient #1) in a total universe of 10 ER (Emergency Room) medical records reviewed.

Findings include:

A review of the facility's policy titled, "Emergency Department Provision of Care" (no last revision date) revealed, "A. When the patient arrives in the Emergency Department... 5. Every patient will have a full set of vitals taken upon admission to the ED (Emergency Department) and thereafter based on the condition of the patient and /or provider order..."

A review of Patient #1's medical record revealed that Patient #1 was a 32-year-old female with a past medical history of two previous miscarriages, asthma, anemia (reduced number of red blood cells), and diverticulitis (inflammation of one of the diverticula) who was presented to the facility's ER on 03/10/2025 at 3:37 PM for bleeding and evaluation after a miscarriage. Patient #1 was evaluated with a transabdominal ultrasound and discharged home for further monitoring of bleeding. Patient #1 presented back to the ER on 03/11/2025 8:49 AM with reports of increased vaginal bleeding. Patient #1 underwent a blood transfusion and was admitted to same-day-surgery for a D&C (Dilation and Curettage).

Further review of the medical record revealed the following note on 03/10/2025 at 7:09 PM RN (Registered Nurse) O: "Rounding comments... Pt (patient) used call light. Pt reports that she was using bathroom when she became lightheaded. Pt also reports that she is feeling nauseous. Pt returned to bed and given juice, Nutri grain bar, cookies, [peanut butter]. Pt. given shirt. Vitals reassessed and pt reports improved in sx (symptoms) feels comfortable with d/c (discharge). Spouse, children, and relative to assist pt to vehicle." Review of the record revealed there was no reassessment of vital signs documented or documentation that ER PA (Physician Assistant) L was notified of Patient #1's change in condition before discharge on 03/10/2025 at 7:21 PM.

During an interview on 07/08/2025 at 2:45 PM with ER RN Manager B, when asked what the expectation is for a patient change in condition (for Patient #1), she stated, "The nurse documented that the vital signs were done but she must have forgot to document it." When asked about the notification of the change in condition, ER RN Manager B stated she did not see this notification documented in the medical record.