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Based on record review and interview the facility failed to follow their policy for patient grievance in 1 of 10 patients (#3 of #1 through #10) whose medical record was reviewed on 5/17/2022.

This deficient practice had the likelihood to effect all patients of the facility.

Findings include

On 5/17/2022 at 9:30 am with the assistance of Staff #5, the medical record (MR) for patient (Pt/pt) #3 was reviewed. Pt #3 was admitted 12/14/2022 through the Emergency Department with multiple fractures of her left lower leg. She was admitted for surgery under the care of orthopedic surgeon #9. After surgical repair pt #3 was placed on cardiac floor for post operative care. Interview with staff #5 confirmed this was the height of the COVID-19 pandemic and beds were a "Premium", there was no bed available on the medical surgical floors. Interview with Staff #1 confirmed the hospital was severely short of their regular staff, related to COVID-19, and used many traveling and RAC (Regional Activation Control) Nurses who were contracted for the pandemic.

Pt #1 complained to the floor supervisor staff #10 on 12/15/2022 that she was not happy about her personal care and wanted to be transferred to another hospital (transfer would have been unlikely related to COVID-19 patient load for all hospitals in the state during this time). However, staff #10 relayed this message to the Hospital, Physician # 8. Physician # 8 notified pt #3's Orthopedic surgeon #9, and together on 12/16/20 the Hospital and the Surgeon met with the family and patient. Both pt #3 and the family agreed she would remain a patient where she was for continuity of surgical care.

Although the house supervisor documented the request to the managers the managers did not consider that pt #3's dissatisfaction with her personal care had not been resolved. The physician who met with the patient did not resolve pt #3's dissatisfaction with her personal care and did not pass the information to the Risk manager.

The patient's complaints of having to wait too long for assistance to go to the bathroom were never addressed. The complaint was never made known and was never resolved. A review of the complaint and grievance log found no complaint from pt #3.


On 5/17/2022 the facility's "Patient Grievance/Complaint Resolution" policy was reviewed.

Policy effective date 9/7/2018.

Purpose:
1. To clarify the process to address, respond, resolve, and track patient compliant's and grievances.
2. This is an organization-wide program. It applies to all care settings and all support documents.

1. It is the policy of CGSHS (the hospital), to implement practices consistent with regulatory standards to manage patient concerns related to the care and services they receive. It is also an organizational policy to assure that patient or family member grievances or compliant's are communicate in a timely, reasonable and consistent manner to the appropriate department for investigation,problem resolution, ad follow-up. Patient concerns shall be categorized.

2. (The hospital) encourages and allows patient and families to voice concerns ad recommend changes freely without being subject to coercion, discrimination, reprisal or unreasonable interruption of care.

3. When the patinet care complaint cannot be resolved at the time of the compliant by associates present, is postponed for later resolution, is referred to another staff member for later resolution, requires investigation, and/or requires further action for resolution, then the compliant is a grievance.

3.1. Staff Present-Includes any associate present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration,nursing supervisor,patient advocate, etc) to resolve the patients's complaint.

The facility staff failed to notify the administration of pt #3's complaint. The compliant was never resolved, and therefore it became a grievance that went unnoticed and was not addressed within the hospital organization.