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Based on record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 2 (#2, #5) of 2 patients reviewed for complaints/grievances from a total patient sample of 5. Findings:

Review of the hospital's policy AD 16.01.00 titled, "Patient Complaint/Grievance Policy" revealed in part: Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect.

Patient #2
Review of Complaint Log revealed a complaint for Patient #2.
Complaint received on 2/25/21, log states "Patient #2 had complaints regarding the ER. In comments, "Patient was called and discussed complaint. These issues will be discussed with staff".

"Confidential Patient Complaint Form" revealed in part: S6MCS took complaint on 02/25/2021 at 9:24 a.m. States that patient stated that she came to ER with leg pain and worst care ever in the ER. Action taken revealed that S2DIME called the patient on several occasions and no answer. On 03/05/2021 S3DOM Patient Advocate called the patient and patient appeared to answer but was holding a conversation with another person so no response. The calls are not going through. Not able to return calls. Section - Was the issue resolved? Not checked yes or no.

3/30/21 at 2:30pm, S2DIME, reviewed complaint form and remembered this complaint. Stated that most patients call administration and talk to S6MCS and she then forwards it to the Patient Advocate. States patient was very hard to get in touch with. When asked if she investigated issue, she stated "yes". When asked if she had documentation of the investigation, she stated "no". When asked if she had talked to MD regarding complaint, she stated no. S2DIME confirmed that this should have been considered a grievance.

3/30/21 at 2:45pm, S1RN stated that there is no more documented evidence of an investigation related to this complaint.

Patient #5
Review of the Complaint Log failed to reveal Patient #5

Review of Patient #5's Medical Record revealed in part: Patient admitted on 09/22/2020 and discharged on 09/27/2020. The Physician's Discharge Summary dated 09/27/2020 revealed the patient was arranged for discharge on the 24th (09/24/2020). Unfortunately she sustained a rather significant skin tear with some subcutaneous fat seen to her right knee on transfer to the wheelchair. I held transfer and had a wound care consult.

"Confidential Patient Complaint Form" date 9/28/20 at 1:34 p.m. revealed in part:
Describe action taken Department Head or Supervisor: Was issue resolved "NO" box checked. If no, provide an explanation: S2DIME talked to patient's daughter. Daughter stated she felt the patient fell when she was in the hospital. S2DIME explained to daughter that the wound to the patient's leg occurred while transferring the patient to the wheelchair. Daughter stated she did not believe that happened from putting the patient in the wheelchair and would file complaint with State.

3/30/21 at 9:30 a.m, S1RN stated complaints are taken care of when patient is in house and a Grievance is written complaint or when patient is not in the hospital and a complaint is reported that cannot be taken care of at that time.

3/30/21 at 2:11 p.m., S2DIME reviewed the Complaint Form and acknowledge it was a grievance and stated she did not forward the information to the patient advocate or administration so a grievance report could be completed.

03/30/2021 at 2:50 p.m., S3DOM stated she was the Patient Advocate from March 2020 through March 2021 and was involved with the complaint/grievance process. After review of Patient #5's Complaint Form, S3DOM acknowledged it was a grievance.

03/31/2021 at 10:07 a.m., S5NAA, the current Patient Advocate stated a grievance is a complaint that can't be resolved immediately or one that requires an investigation. S5NAA did not recall speaking with Patient #5's daughter regarding the patient and an incident at the hospital.

03/31/2021 at 10:16 a.m., S6MSC stated she answers all the incoming administration phone calls for all administration and records the details of any complaint. S6MSC continued to state a complaint was received post discharge by telephone regarding Patient #5 and she forwarded the information she received from the patient's daughter to S3DOM and S2DIME.

Based on record review and interview, the hospital failed to ensure adverse patient events were tracked through the Quality Assurance Performance Improvement program. This deficient practice was evidenced by 1 (#5) of 5 patient's records reviewed for Incident reports not having an incident report for an adverse event out of a total patient sample of 5.
Findings:

Review of the hospital's policy titled, "Incident Reporting" revealed in part:
It is the policy of the hospital that all patient adverse events and incidents are reported as soon as know, and within 24 hours.
Patient Safety Events - Events that may have resulted in patient injury.
All patient safety events require reporting on an Incident form.

Review of Patient #5's Medical Record revealed in part: Patient admitted on 09/22/2020 and discharged on 09/27/2020. The Physician's Discharge Summary dated 09/27/2020 revealed the patient was arranged for discharge on the 24th (09/24/2020). Unfortunately she sustained a rather significant skin tear with some subcutaneous fat seen to her right knee on transfer to the wheelchair. I held transfer and had a wound care consult.

Review of the Incident Log failed to reveal an Incident Report for Patient #5.

3/30/21 at 1:30 p.m., S1RN stated an Incident Report was not completed for Patient #5.

3/31/21 9:05 a.m., S4LPN, after reviewing facility complaint form, stated she recalled Patient #5's injury but she did not file an incident report at the time of the injury.