HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to acknowledge, investigate and resolve a patient's grievance for one (1) of eight (8) Patients (P), P # 5.

The findings include:

On April 10, 2025 at approximately 11:00 AM, a review of the facility's complaint/grievance log from July 2024 to present revealed no complaint and/or grievance for P # 5.

At approximately 11:15 AM, Staff Member (SM) # 5 provided an email dated August 5, 2024 sent by SM # 6. The email was sent to SM # 5 and # 7 and stated "I looked into this complaint".

At 11:20 AM, interviews with SM # 2 and SM # 5 were conducted regarding why the complaint was not on the compliant/grievance log. SM # 2 stated "I am not sure; it should have triggered a complaint in the system".

At 12:30 PM, an interview with SM # 2 revealed "the complaint was emailed on August 1, 2024 via the "800 web promise line" (facility complaint/grievance reporting) which triggered emails and should have trigger a facility patient advocate response. However, it was never acknowledged by the facility."

There was no documentation provided by the facility to show that P # 5 received an acknowledgement or resolution for the complaint filed on August 1, 2024.

At 1:00 PM, a review of the facility's policy titled "Complaints and Grievances" reads in part "Acknowledge by telephone call within two (2) business days of receipt.
Investigate unresolved verbal complaints and written grievances. If the grievance will not be resolved with 7 calendar days, write an acknowledgement letter within 7 days. If the investigation will not be completed with the 30 days, write an extension letter.
Write Final response letter within 7 calendar days of receipt."