HospitalInspections.org

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Based on document review and interview, the facility failed to implement its policy and procedure on Patient Complaints and Grievances to investigate grievances and provide a written notice of its decision that includes the result of the investigation.

Findings include:

Review of the policy "Patient Complaints and Grievances, including ADA/Section 504 Grievance Procedure, Centralization and Management (Effective 09/2019) revealed that for complaints received verbally "an investigation is initiated, and a response is provided to the patient or patient's designated representative usually within 24 hours ...And for written grievances, the hospital shall promptly notify their patient/representative in writing that the grievance has been received...and will follow up with a final written response..."

Review of Patient complaint files on 12/17/21 identified a complaint that was filed by a patient's next of kin on 8/17/21. The complaint noted that "the patient is not receiving good care during the night. One night the patient called for help and no one responded. Also, the patient noticed a staff sleeping in his room.

The complaint file revealed the complaint was forwarded to the Unit Manager who would follow up with the night staff.

There was no documented resolution to the specific complaints made by the patient's next of kin. Instead, it was documented that the patient representative assisted patient's next of kin to access My Chart and Patient Representative made sure the patient had all valuables and belongings with him.

During interview with Staff A (4 East Nurse Manager) on 12/20/21 at approximately 11:16 am, staff reported that the patient's complaints were investigated and unsubstantiated. Staff A stated that an in-service education was provided to the night shift but was unable to provide any documentation of the training provided.

During interview with Staff B (Director of Patient Representatives) on 12/20/21 at 12:03 pm, staff acknowledged findings and stated that the complaint/grievance resolution process was not completed.