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Based on document review, policy review, record review, and interview, the Patient Advocate failed to ensure the effective operation of the grievance process for one of eight patients reviewed (Patient 1). This deficient practice has the potential to lead to harm or other adverse outcomes.

Findings Include:

Review of the Hospital's policy, "Patient Complaints and Grievances," dated 03/08/22, showed "a grievance is a formal or informal written or verbal complaint that is made to the hospital . . . patient complaints that are considered grievances also include situations when a patient or patient's representative telephones the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs [Conditions of Participation] or other CMS [Centers for Medicare & Medicaid] requirements after the patient has been discharged . . . When a staff member resolves a complaint of clinical nature from the patient or patient's representative, the staff member shall document (or see that the complaint is documented) in the patient's record including the resolution of the complaint as agreed upon with the patient." Further review showed, "Any staff member who receives a verbal grievance shall immediately forward it to the hospital Patient Advocate . . . log the receipt of the grievance . . . maintain the tracking log of the grievance . . . send a resolution letter within seven (7) days of the receipt of the grievance . . . Grievances shall be reviewed and responded to in a timely manner . . . Grievances involving situations which endanger a patient shall be reviewed immediately . . . information obtained throughout the investigation process shall be documented . . .compile a final summary of the investigation and respond to the grievance with actions taken to resolve the grievance on the patient's behalf."

Review of Patient 1's discharged medical record showed a 60-year old male who was involuntarily admitted on 03/20/22 after exhibiting alcohol induced verbal aggression, paranoia and delusional behavior scaring his neighbors Patient 1 was diagnosed with alcohol-induced bipolar (a serious mental illness characterized by extreme mood swings that can include extreme excitement episodes or extreme depressive feelings) and related disorder with moderate or severe use disorder, tobacco use disorder, gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), complete edentulism (the loss of all teeth) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) by history. Patient 1 was discharged on 03/25/22, per court order.

Review of an email dated 04/25/22 at 2:01 PM, Staff A, Director of Social Services, showed, "I spoke to sister [F1] today. She said, 'he is still missing, you are responsible, you have to find him, and you have to fix it.' She asked about where he discharged to and when I tried to explain she cut me off and said, there is no way her parents would accept him back, he had no place to stay, no way to communicate, and we need to be accountable for "dumping him on the streets."

Review of the Hospital's grievance log dated 03/01/22 to date of survey showed that F1's concerns were not addressed through the grievance process according to the Hospital's policy.

During an interview on 06/21/22 Staff D, Registered Nurse (RN), stated that the complaints from F1 were handled by Staff A, Director of Social Services, and was not considered an official grievance.