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Based on a review of facility documents and staff interview, the facility failed followed their Grievance Policy resulting in the failure to investigate 2 of 4 (Patients #1 and #2) grievances reviewed.

Findings included:

Facility Policy titled "BSSH RI.33 (PR) BBSH Grievance Process, effective 6/25/29 and last reviewed 9/21", stated in part ...
" ...V. Definition:
Grievance: A formal or informal verbal or written complaint that is made to the hospital by a patient, or the patient's representative when a problem cannot be resolved promptly on the spot by staff present or arriving promptly to the unit to resolve the problem. If a complaint cannot be resolved promptly by staff present or is referred by staff to the Consumer Services and Rights Office (BSSH Rights Protection) or hospital management, it is to be considered a grievance ...
B. Grievance Protocol. The following process will be utilized to ensure our patient and the appropriate staff is provided with the proper information regarding BSSH Grievances.
1. When a verbal or written grievance is received from a patient or legally authorized representative by any staff person at the hospital and it cannot be satisfactorily resolved by Unit Staff, the Rights Protection office shall be notified. The Director of Rights Protection or designee is the "investigator" for the grievance and shall meet with the patient and/or legally authorized representative to obtain additional details about the grievance filed including the details about the date, time, witnesses and other facts relevant to the grievance. This meeting will take place within 48 hours of the investigator being assigned the grievance ..."

During a telephone interview on the afternoon of 12/16/24 the complainant related to patient #1, reported that she had a difficult time getting to visit Patient #1. Each time she went she was told that she had to wait even if she called to ensure she would be able to visit at a certain time. During one visit she was very upset, and the staff told her that she had to leave, or the police would be called. Staff #1 was called, and they discussed the issue. The complaisant continued that the police were called, and she was charged with criminal trespassing."
During a telephone interview, on the afternoon of 12/16/24, the complainant for patient #2, reported that she called and complained about the patient's condition when he arrived at her home. She continued that she felt that the information about his true condition had not been communicated with her prior to the patient being accepted to her home. Shortly after the patient arrived at her home, he was rushed to the hospital for emergency surgery where the patient was diagnosed with colon cancer.
During an interview, on the morning of 12/17/24, Staff # 3 reported that they had received a request for information about patient #2 related to a complaint that protective services had received. She continued that they never came into the facility to investigate.
During an interview, on the afternoon of 12/17/24, Staff # 1 reported that "they called me at home. I could hear her screaming in the background. We communicated multiple times after this incident." When this surveyor reviewed the definition of a grievance, she verified that this should have been a grievance. She continued that neither of the complaints (Patient #1 and Patient #2) were identified as grievances. They were not entered into the complaint/grievance log. They were reviewed, just not documented into the grievance database.

Based on a review of facility documents and staff interview, the facility failed to ensure the hospital investigated 2 of 4 (Patients #1 and #2) grievances reviewed and notified the patient's representatives of its resolution.

Findings included:

Facility Policy titled "BSSH RI.33 (PR) BBSH Grievance Process, effective 6/25/29 and last reviewed 9/21", stated in part ...
" ...V. Definition:
Grievance: A formal or informal verbal or written complaint that is made to the hospital by a patient, or the patient's representative when a problem cannot be resolved promptly on the spot by staff present or arriving promptly to the unit to resolve the problem. If a complaint cannot be resolved promptly by staff present or is referred by staff to the Consumer Services and Rights Office (BSSH Rights Protection) or hospital management, it is to be considered a grievance ...
A. Grievance Protocol. The following process will be utilized to ensure our patient and the appropriate staff is provided with the proper information regarding BSSH Grievances.
1. When a verbal or written grievance is received from a patient or legally authorized representative by any staff person at the hospital and it cannot be satisfactorily resolved by Unit Staff, the Rights Protection office shall be notified. The Director of Rights Protection or designee is the "investigator" for the grievance and shall meet with the patient and/or legally authorized representative to obtain additional details about the grievance filed including the details about the date, time, witnesses and other facts relevant to the grievance. This meeting will take place within 48 hours of the investigator being assigned the grievance ...
5. The Consumer Services and Rights Officer shall draft a response letter to the patient and/or patient's legally authorized representative that contains the name of the hospital's 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 ..."

During an interview, on the afternoon of 12/17/24, Staff # 1 reported that neither of the complaints (Patient #1 and Patient #2) were identified as grievances. They were not entered into the complaint/grievance log. They were reviewed, just not documented into the grievance database.
During an interview, on the afternoon of 12/17/24, Staff # 3 verified that no letter was sent to the complainants.