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Based on record review and interview the facility failed to provide a written response to the complainant regarding the outcome of the complaint/grievance investigation in 1 of 2 patient complaints/grievances reviewed (Patient (Pt) #1) in a total sample of 2 patient complaints/grievances reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Complaint/Grievance Process" last revised 03/2022 revealed the following:
-A written complaint is always considered a grievance.
-A grievance will be considered resolved when the patient is satisfied with written notice of resolution.
-Resolution of the grievance should be completed within 7 days depending upon the nature of the grievance.
-Within 7 days of notification the complainant will be provided with written notice of the health system's decision and will include at a minimum:
1. The name of the health system contact person
2. The steps taken to investigate the grievance
3. The results of the grievance process, and
4. The date of completion
-Grievance investigations should be completed and the final response sent within 30 days.

Review of complaints/grievances revealed Family A emailed a complaint/grievance to the hospital on 09/29/2022 in regards to Pt #1 not receiving an autopsy and being transferred to the funeral home (09/27/2022 at 2:00 am) after Family B signed the consent for autopsy on 09/26/2022 (no time). The hospital sent Family A an initial follow up letter, acknowledging Family A's complaint dated 09/29/2022.

Per interview with Quality Director C on 12/01/2022 beginning at 1:23 pm, Quality C stated that a final response letter has not been sent to Family A in response to Family A's complaint/grievance submitted on 09/29/2022 (62 days). Per Patient Complaint/Grievance policy this should be done within 30 days.

Per interview with Family A on 12/01/2022 at 12:27 pm, Family A stated that she/he did not receive a written notice addressing the actions completed to investigate and resolve Family A's complaint/grievance.

Based on interview and record review the facility failed to implement a preventative action plan related to failing to perform an autopsy as per policy at family request in 1 of 10 death records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Autopsy" last revised 06/2021 revealed, "An autopsy may be requested for inpatients who expire." The Autopsy policy revealed the following,
-A request can be initiated by legal next of kin. It must be signed by the legal next of kin.
-Contact physician to place order for autopsy in the electronic medical record
-Complete consent for autopsy form and witness
-Nursing Supervisor will notify Pathologist

Review of Family B's complaint/grievance emailed to the hospital on 10/01/2022 at 10:27 am, revealed, "My father, (Pt #1), passed away on September 26 in the Cardiac Intensive Care Unit (CICU). I understand his case is under review. There is something I don't understand, however. (Pt #1) died approximately 9 p.m. Before I left the CICU, I filled out a paper requesting that an autopsy be performed...my mom and I were told that the autopsy would happen at 7 a.m. the next day. It is my understanding that the funeral home picked up (Pt #1's) body at 2 a.m., five hours later. The Funeral Director told me there was no indication that an autopsy was performed. I just want to know why the autopsy was not done."

Per review of Pt #1's medical record, there was no evidence of a physician order for autopsy as per policy. Review of Pt #1's medical record, revealed Family B signed a "Consent for Post-Mortem Examination (autopsy)" on 09/26/2022 (no time) and the form revealed, "After the post-mortem examination, I (Family B) instruct the body to be delivered to (funeral home)."

Per interview with Quality D on 12/01/2022 at 1:50 pm during Pt #1's medical record review, Quality C stated that she/he was unable to find a physician order for autopsy.

Review of the complaint/grievance follow up letter written by Quality Director C (sent to Family B), dated 10/07/2022, revealed, "As the Director of Quality for Beloit Health System, I have completed my investigation including medical record review, caregiver interviews and policy review...we learned that there was a miscommunication and a failure to follow the process in place. As a result of this investigation, we will determine if changes are needed in our policies and will provide additional education to ensure everyone understands the process to obtain an autopsy when appropriate.

Per interview with Quality Director C, Quality Manager D, and Vice President E on 12/01/2022 beginning at 1:23 pm, Quality C stated that a root cause analysis was completed and it was determined there was a break down in communication. Quality D stated that they looked at the policy and decided that the workflow was "cumbersome". Per Quality D, there are 2 different processes to follow for autopsies based on whether it is day or night, and it can be confusing for staff. Quality C stated based on the investigation, staff have decided that the death paper work will be going to the night shift supervisor and not the ED registrar "So paper work was not going through so many hands." Quality C and Quality D stated that an action plan was developed, including updating policies, educating staff and changing electronic medical records documentation; however, this action plan has not yet been implemented.