HospitalInspections.org

BASED ON record review and interview, the facility failed to ensure the patient's right of a written response including its decision, the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for the 10/17/2024 post hospitalization quality of care grievance for Patient #1.

Findings

The facility's complaint/grievance noted, "10/17/2024 event...Patient Complaint/Grievance...hospital...did not give her 72 hours to decide on a funeral home and hospital released baby without her consent...baby transferred to 4 different cremation places...Tuesday of this week...(Patient #1's name) at desk requesting medical records and stating hospital killed her baby with some medication they gave her...no action required..."

There was no grievance response from the facility to the complaiant.

During interview on 12/10/2024 at 12:50 PM, Personnel #7 was asked if the Patient #1's 10/17/2024 quality of care complaint was provided a grievance response letter after an investigation. Personnel #7 stated no, they attempted to call her three times and she did not respond. We like to talk to them to clarify and they were not able to get ahold of her.

The facility's June 2024 effective date, "Patient Grievance and Complaint Management Policy" required, "PURPOSE:
A. To establish a process for timely referral, prompt review, investigation and resolution of patient grievances and complaints ...Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489...
C. Grievance Resolution Process
1. Grievances may be received written, verbally, via electronic mail, postal service, or by telephone to any department. Patient care complaints received via the Corporate Ethics Line to the Corporate Ethics and Compliance Department and complaints received via email, postal service, or telephone at the Corporate Office are forwarded to the HCA Healthcare Regulatory and Accreditation Services Department. These complaints are entered into the electronic safety surveillance system under Patient Experience and are assigned to individuals responsible for completion of the investigation and communication of resolution to the complainant. The HCA Healthcare Regulatory and Accreditation Services Department facilitates this process to ensure resolution and compliance with regulatory standards.
2. Upon receipt of a grievance, the Patient Advocate shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues.
3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days. (Timeframe established by the Corporate Ethics and Compliance Department.)
4. Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.
5. In resolution of the grievance, a written notice of the decision must be provided to the patient or patient's representative that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion..."