HospitalInspections.org

Based on policy and procedure review, incident report review, grievance log review and staff interviews, the hospital failed to identify an allegation of patient abuse as a grievance and respond per hospital policy for 1 of 3 patient care complaints reviewed (Patient #8).

The findings include:

Review of the hospital's policy titled, "Patient Complaint and Grievance Reporting, H-05-13 last revised on 02/2020 revealed, "POLICY: ...DEFINITIONS: ...A Patient Complaint can be and is resolved at the time of the complaint by staff present ...Patient Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient or the patients representative, regarding the patients care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation ...Resolved: A complaint or grievance is considered resolved when the patient is satisfied with the actions taken on their behalf ...MAJOR PROBLEM CATEGORY: ...Abuse, Harassment, or mistreatment. All allegations ...will be reported immediately to the Department Leader or House Supervisor ...as soon as possible ...An immediate investigation will be made, and the findings of such investigation reported to the CEO ...PROCEDURE: A ...B ...If unable to resolve, the patient will be informed, and the complaint will be referred to the Grievance Committee for resolution or investigation. Follow-up will be provided to the patient or the patient's representative ...C ...3. Patient Grievance Form: All patient grievances will be documented on a formal Patient Grievance Form ...or provided through written supporting correspondence ...i ...ii. The Patient Grievance Form will be forwarded to the appropriate Department Director and/or persons involved who can provide resolution to the grievance within (8) eight hours if possible. The Department Director and/or persons involved must provide a response to the grievance to the patient or patient's representative within (5) five days. The response must provide the results of the investigation, including steps taken to resolve the grievance on behalf of the patient, if necessary ...If the Department Leader and/or persons involved need additional time ...cannot provide a response within five (5) days of receiving ...they must contact Administration requesting a five (5) day extension, citing the reason ...D. Resolution: Administration will send a letter of resolution to the complainant by day seven (7) of receiving the grievance. The letter of resolution will include the steps taken to resolve the grievance ...date of completion and the name and phone number of the person sending the resolution letter. If the grievance requires additional time ...an extension letter will be sent to the complainant by day seven (7) informing them that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response stating the specific date of resolution not to exceed seven (7) calendar days from the day seven (7) notice."

Review of internal hospital documents revealed an Incident Report dated 12/20/2020 at 1900 with an "Event Type: Abuse/Assault ..." The Incident Report revealed there was an allegation of abuse towards Patient #8. Review of the hospital's Grievance Log through December 2020 revealed no complaint on behalf of Patient #8 was logged.

Request for evidence that the grievance policy was followed revealed there was no documentation.

Review of the closed medical record for Patient #8 revealed the 87 year old male was admitted to the hospital from 12/14/2020 through 12/20/2020, for "Pneumonia due to Covid-19 virus." Record review revealed a diagnosis of "Dementia" was on the Active Problem List for Patient #8.

Interview on 01/26/2021 at 1619 with the Department Leader (DL)/Risk Director (RD) revealed, "If a patient is here at the time the complaint comes in, then the Department Director handles it, so it would not be a grievance ...If unable to resolve, then it would be a grievance." The DL/RD revealed that there had been an allegation of abuse towards Patient #8 and it was not treated as a grievance. A follow-up interview on 01/27/2021 with the DL/RD revealed, "We worked hard...did everything except for the grievance part. We had a checklist but hadn't used it yet because the CNO was tweaking it." Interview revealed the hospital's grievance policy was not followed.

Interview on 01/28/2021 at 0920 with the Chief Executive Officer (CEO) revealed, "I had a check list from a previous facility, and I gave it to (named CNO) ...They didn't use it this time. If they had used the checklist, it would have been placed on the grievance log." Interview revealed the hospital's grievance policy was not followed.

Interview on 01/28/2021 at 1450 with the Chief Nursing Officer (CNO) revealed, "We know we should have treated this as a grievance and going forward we will use the checklist to make sure we don't miss anything. We did the investigation but didn't follow through with a letter to (named patient representative) because it wasn't treated as a grievance." Interview revealed the hospital's grievance policy was not followed.

NC00172786