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Based on document review and interview, the hospital failed to provide written notice of decisions made through investigation of grievances and/or the results of the grievance process for 2 of 2 patients with a grievance (P2 and P8).

Findings include:

1. Review of the Patient Grievance/Complaint Policy, last review date 4/12/21, indicated the following:
Definitions: Grievance: A formal or informal, written, or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made to the hospital by a patient, or the patient's representative, regarding the patient care provided, abuse, or neglect, or the hospital's compliance.
Grievance Procedure: The written response provided to the patient will address the substance of each patient grievance as soon as possible. The hospital will facilitate a written response to the patient or patient's representative within seven (7) days from the date of receipt of a patient grievance. If the grievance is not resolved within seven (7) days, a letter will be sent to acknowledge that the hospital is working to resolve the grievance. The acknowledgement letter will indicate an expected timeframe for resolution or a follow-up response. If the patient grievance is not resolved within (30) days, an extension letter will be sent to acknowledge that the hospital is still reviewing the concerns. The extension letter will indicate an expected timeframe for a follow-up response. An extension letter will be sent every (30) days until the grievance is resolved.

2. Review of facility complaints and grievances (MIDAS reports) indicated the following complaints/grievances had been entered for 2 patients in MR review (P2 and P8) with information indicated as follows:
a. Report 22-669.
i. On 6/22/22, patient P8 left a voice message indicating he/she would like to file a complaint for malpractice due to a radiology misread/inadequate treatment of a fracture.
ii. Correspondence with the complainant indicated the hospital sent P8 an initial letter on 6/30/22. The letter lacked documentation of resolution of the grievance, information that the hospital was still working to resolve the grievance and/or a number of days in which the hospital would follow-up with a response.
iii. On 7/12/22, a second letter was sent to P8 which indicated the case was sent for a secondary review. The letter lacked documentation of the date of completion.

b. Report 22-737.
i. Family member, F1, of patient P2 complained that patient P2 was re-admitted for hip surgery, needed to go to a skilled nursing facility (SNF) after discharge, and that interactions with Social Worker (SW) C3 were upsetting. F1 requested another SW. The note lacked documentation of resolution at the time of event and/or call. Records lacked evidence of actions taken, the concerns having been investigated and/or resolved as a complaint/grievance and lacked evidence of an initial letter having been sent.
ii. MIDAS (hospital event reporting system) report documentation indicated that on 7/26/22, the facility received a grievance letter from F1 and reassigned the complaint as a grievance as of 7/26/22. The letter expressed grievances with 6/21/22 Emergency Department (ED) care/treatment related to hip pain and radiology reports as well as delay in discharge coordination by SW C2 and communication issues with C3.
iii. Email documentation dated 7/26/22 indicated correspondence was sent to F1 noting reviews may take 30 days to complete. The correspondence lacked documentation that the hospital would follow-up with a written response within a stated number of days.
iv. On 8/15/22, notes indicated Quality received a referral for review process by MSQC (Medical Staff Quality Committee).
v. Follow-up letter addressed to F1 with a date of 8/18/22 indicated review of findings was completed 8/18/22. Internal Quality Review of the ED visit allegation(s) had been evaluated through their Internal Quality Review process. The letter lacked documentation of results of Internal Quality Review process. The letter lacked documentation of the investigation having been extended.

3. On 9/1/22, the following was indicated in interview:
a. Beginning at approximately 2:00 PM, A5, Patient Relations Manager, verified the concerns expressed by F1 had initially been entered as a complaint and not a grievance until F1 sent a written letter. A5 indicated the email sent 7/26/22 was the 7 day/initial letter and the final grievance follow-up letter was sent on 8/19/22. A5 verified the letters lacked documentation of timeframes for review of the grievance, date of completion and/or provision of a response with decisions.
b. Beginning at approximately 3:30 PM, A1, Accreditation and Regulatory Officer, indicated no information for MSQC review of MIDAS event 22-737 was available due to the committee not yet having met for the quarter to review the event.

Based on document review and interview, the hospital failed to ensure discharge planning evaluations were made in a timely basis to avoid delays in discharge for 1 of 10 patients (P2).

Findings include:

1. Review of the policy titled Patient Discharge Planning and Discharge Procedure, last review date 8/3/20, indicated the following:
Purpose: To identify the appropriate discharge destination that meets the needs of the patient.
Definitions: The discharge plan focuses on the patient's goals and treatment preferences and includes the patient and his/her caregivers/support persons as active partners.
Responsibilities: Case Management Services: Consults are responded to in a manner so that appropriate arrangements for post-hospital care are made before discharge. Quality is responsible for reassessing the effectiveness of the discharge planning process.

2. Review of complaint/grievance/Midas report 22-737 indicated in an 8/4/22 entry by A4, Case Management Manager: Many opportunities for improvement were discovered. Including: Referrals in timely manner. Communication, as well as referral follow-up in timely manner. Factors: Weekend and holiday. CM short staffed. Education will be given on ways to prevent future issues and to create/provide best experience. In a follow-up letter to the patient's family member, F1, dated 8/18/22, the following was indicated: The CM reviewed the case and found opportunities for improvement. Based on these findings, education was given to the entire team.

3. Review of personnel files of staff named in the grievance allegations, Social Worker (SW) C2, Master of Social Work/Social Services Designee II and C3, RN/Acute Care Case Manger Team Leader, lacked evidence of education provided to C3.

4. On 9/1/22, beginning at approximately 5:45 PM, A4 indicated education of staff related to MIDAS case 22-737 was provided only to C2 and another employee involved in the issue. A4 verified no education/discussion was provided to C3, nor was there documented investigation into the allegations pertaining to C3. A4 also indicated the hospital did not have evidence of education provided to the entire team as indicated in the above noted follow-up letter.