HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure that a process for the resolution of patient grievances was implemented per hospital policy and regulatory requirements. This resulted in inaccurate/incomplete reporting of patient complaints and grievances to hospital leadership, as well as a lack of follow-up with patients or their legal representatives/family. In addition, systemic issues regarding hospital patient care had the potential of remaining unidentified and unaddressed.

Findings were:

" ...PURPOSE:

This policy outlines the process for review and management of patient complaints and grievance as prescribed in 482.13 (a) of the Condition of Participation (COP) and Joint Commission Standards ...

B. "Grievance" is a formal written or verbal complaint that is made to the hospital by a patient, or the patient's representative (these include any request that their complaint be handled as a formal grievance with a response). Grievances include, but are not limited to complaint made about the following:
1. the patient's care when not able to be resolved by staff present (i.e., requires further investigation or additional action for resolution at a later time or another party) ...
3. the hospitals [sic] compliance with the CMS conditions of participation ...
Verbal issues #1-4 above, that would routinely have been handles by staff present if the communication had occurred during the relevant visit are not Grievances for purposes of this policy ...
IV. POLICY:

The patient shall have the ability to file a complaint or grievance as part of the patient rights process and in compliance with the Medicare COP and Joint Commission Standards. Patients registering complaints and/or grievances shall not be subjected to retaliation and/or barriers to service. The Hospital's process for managing complaints and grievances must incorporate the following objectives: ...

C. Provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by patients and/or patient representatives.

D. Provide an on-going system for monitoring and trending patient complaints and grievances.

V. PROCEDURE: ...
C. Patient Grievance
1. Complaints meeting the definition of a grievance will be forwarded to the manager/director of the affected department for investigation and resolution.

2. If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director shall forward a copy of the Patient and Family Complaint/Grievance report to the Director, Clinical Quality Improvement (DCQI) or the Patient Safety Officer for action ...

3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response in 7 days ... If the resolution of the grievance is determined to take longer than seven days, the Grievance Committee or designee will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response ...

4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and the patient's legal representative understands within 30 days ...

6. The Patient Safety Officer will maintain a log that provides response to the patient ...The Hospital's Quality Management department will incorporate grievances into the complaint/grievance data set, which will be aggregated, analyzed and reported quarterly to the designated Grievance Committee, Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Committee, MEC (Medical Executive Committee), and the Governing Board ..."

A review of the hospital grievance log from September 2020 through date of survey revealed only 4 grievances for this time period. Surveyors on-site on the date of survey were aware of 3 patient grievances - 3 patient complaints being investigated - that the facility:
+ had been aware of
+ had not considered grievances though they met the regulatory definition of grievances
+ had no documented evidence of having investigated
+ could provide no documented evidence of having responded to the patient or patient's representative.

In an interview with Staff #5, Patient Safety Officer, on the afternoon of 5/25/21 at 2:15 p.m. in the small hospital conference room, he discussed how he defined a grievance. He stated, "If a patient is discharged, we consider it a grievance. We'll ask if the person or the representative feels they have closure. We ask them "Would you like follow-up?" - a letter, something." When asked if they keep a log of patient complaints not considered grievances, he stated the hospital did not.

In a subsequent interview with Staff #5 on the morning of 5/26/21 at 10:40 a.m. in the same location, he restated his definition of a patient grievance, and added, "It's a grievance after a patient has left." He added that the hospital system, "probably as a whole needs to revisit the way we look at grievances." When asked about the 3 patient grievances being investigated by surveyors and why they weren't on the grievance log, he had no answer. Hospital administrative staff had already acknowledged the facility was aware of each of the 3 grievances.