HospitalInspections.org

Based on document review and interview, it was determined the facility staff failed to document and resolve a grievance within a timely and reasonable manner for one (1) out of three (3) patients reviewed.

The findings include:

During surveyor contact with the complainant by telephone on 02/27/23 at 1:33 pm, the complainant stated they reported a quality of care concern regarding Patient #1 to the facility "without ever hearing back".

The surveyor interviewed Staff Member #9 on 02/28/23 at 4:19 pm. Staff Member #9 confirmed with surveyor that they had received a missed call from the foster parent (complainant) of Patient #1, and that a voicemail message was received with detailed concerns regarding Patient #1's care.

Staff Member #9 informed the surveyor that they were unsure when the quality-of-care issues were received as they "no longer have the voicemail" message but that it occurred "sometime after" Patient #1's discharge on 01/10/23. Staff Member #9 stated following an unsuccessful attempt in reaching the foster parent, they had relayed the information to Staff Member #11 (Clinical Program Director).

The surveyor interviewed Staff Member #11 on 02/28/23 at 4:26 pm. Staff Member #11 confirmed they did receive a report from Staff Member #9 regarding the concerns. Staff Member #11 advised during the interview that no further attempts to reach the foster parent were made, nor was an investigation ever conducted regarding the concerns.

Staff Member #2 supplied the surveyor with a list of all reported complaints and grievances for the facility for the past twelve (12) calendar months. Upon review, the surveyor was unable to identify a report submitted on the behalf of Patient #1.

Staff Member #2 supplied the surveyor with the facility policy titled, "Patient/Family Complaint, Resolution, Hearing & Appeal Process" policy (with last revision date of 02/2020) in the afternoon of 02/28/23. In the second paragraph of the document reads, "For the purpose of this policy, a grievance is defined as a "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS [The Centers for Medicare & Medicaid Services] Hospital Conditions of Participation (COPs), or a Medicare beneficiary billing complaint ...".

The same policy continues to read, "If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolutions, then the complaint is a grievance for the purposes of these requirements".

Under "Grievance Process:" section, the policy states, "The staff member receiving a verbal or written grievance shall insure that a "Patient/Resident Concern Notification" is completed and notify the Patient Advocate or Shift Supervisor. The patient advocate or in his/her absence, the Shift Supervisor shall investigate and address the grievance within 24 hours of the time the grievance is received if possible. If the concern cannot be resolved at this level, the patient/resident advocate will facilitate the investigation and resolution of the grievance through a complete investigation by the appropriate department head".

The same policy continues to say, "The patient/resident advocate responding to the grievance shall inform the patient/resident or family the timeframe within which he/she shall expect follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient/resident shall be notified of the need for an extended time frame and an agreement made as to when follow up will occur. Once the issue has been resolved, the Patient Advocate shall provide a timely written response to the patient/resident and/or family member".
Under "Responsibilities" section, the grievance policy states to "maintain [sic] a log or file of grievances for tracking or trending".