HospitalInspections.org

Based on review of documents and staff interview, it was determined the facility failed to ensure the policy is being followed in relation to grievances and the provision of a response. This has the potential to negatively affect all persons filing complaints with the facility in that their concerns are not being met in a timely manner.

Findings include:

1. The hospital policy entitled "Patient/Family Complaints & Grievance Management", last revised May 2014, states in part: "A grievance includes...all verbal complaints...regarding the patient's care of services when the issue cannot be resolved at the time of the complaint by the staff present...Each CAMC Hospital and CAMC's Ambulatory Services shall establish and maintain a grievance committee to review, assess, and resolve grievances...Each grievance committee shall investigate all reported grievances or specifically designate other staff to do so...Every effort will be made by staff present to promptly address and resolve any complaint made by a patient or responsible party using the applicable service recovery process. If the complaint cannot be resolved with the service recovery process, the staff present should refer the issue to their manager or designee..All grievances will be documented using the Quantros Feedback Manager online tracking program with timely and appropriate review conducted. Information from the review will be used to respond to the grievance...A grievance is considered resolved when the patient or the patient's representative is satisfied with the actions taken...Once the grievance is resolved or closed, the patient or the patient's representative will be provided a written response which will include: 1. Name of the CAMC contact person 2. Steps taken to review and resolve the grievance 3. The results of the investigation 4. Date of completion...This letter will include a notice of the complainant's right to refer the grievance to the appropriate regulatory and accrediting organizations...Copies (electronic or paper) of the grievance will be maintained within the Quantros database for seven (7) years."

2. During review of the medical record for patient #10, documentation found in the nursing notes revealed the ICU nurse caring for the patient on the 7 a.m. to 7 p.m. shift on 10/14/14 was informed by the patient's daughter that she wanted the patient transferred to St. Mary's (Medical Center). Further nursing documentation revealed the daughter called the ICU again on 10/16/14 and spoke with a dayshift nurse about transferring the patient. Additional documentation in the nursing notes on 10/16/14 revealed the Nursing Supervisor also spoke with the daughter about her request to have the patient transferred to another facility.

3. During an interview with the Chief Nursing Officer (CNO) on 12/2/14 at 11:10 a.m., she stated she became aware of the complaint when the patient's daughter came to her office 10/17/14 to voice her dissatisfaction with the care her mother had received. She stated she was also informed by the daughter that the family wanted the patient transferred. The CNO stated that she did not document any of the actions she took to resolve the situation and she did not initiate the complaint/grievance process.

4. During an interview with the Nursing Supervisor on 12/2/14 at 1:00 p.m., she stated she was aware of the family's complaint regarding the care received by the patient and she was aware of the request for transfer but she did not initiate any formal complaint/grievance process for that incident.

5. The ICU Nurse Manager was interviewed on 12/2/14 at 2:15 p.m. She stated she was aware the patient's family had complained about the patient's care and that the family wanted the patient transferred to another facility. She also stated that she had spoken with the patient's family about about their dissatisfaction with the patient's care and had worked with the CNO to get some issues resolved. She stated she did not document the complaint or any of the actions she had taken to resolve the matter.

6. A joint interview with the Clinical Quality Knowledge Coordinator (CQKC) and the Director of Quality & Risk Management (DQRM) on 12/03/14 at 1225. The CQKC stated there was no complaint information entered into the Quantros system and no follow-up letter was sent to the patient/family about their complaint. The DQRM stated the family's complaint was not entered into the Quantros system as per policy. She stated, "I'm not sure where it was dropped. I may need to go over the complaint & 'take the heat process' with staff" to ensure staff understands when to initiate the complaint/grievance process in Quantros.