HospitalInspections.org

Based on record review and interview the facility failed to follow it's policy for responding to patient complaints and grievances for 1 of 1 Patients (Pt. #1) in a sample of 1 of 1 complaints reviewed:

Findings:

Pt. #1 was admitted on 06/21/2023 following a vehicle rollover and left AMA (Against Medical Advise) on 06/22/2023. In a telephone interview on 10/25/2023 at 12:00 PM with Pt. #1, Pt. #1 stated, "I gave them my contact information and expressed my concerns about the care I received and why I felt the need to leave the hospital on the discharge survey back in July, I still have not heard anything about my complaint."

Review of Facility policy #3PE3E66MX2CW-2-1227, last revised 09/30/2022, titled, "Patient Complaint and Grievance Resolution Policy," revealed, "2.2 Definitions:....Patient Complaint: An expression of dissatisfaction with services provided....Information written by patients on satisfaction surveys is generally considered a complaint.... 3.5 Complaint Investigation and Review a. Department or unit managers or assistant managers are responsible for: initial investigation of complaints, staff follow-up, documentation in the file of corrective steps taken, or how feedback will be used for improvements, tasking additional managers who may need to be engaged, or Patient Experience team if additional action is needed, sign off on the file. B. Patient experience is responsible for ensuring file is updated and complete, including but not limited to: Investigation progress and correspondence, documentation of file progression and actions taken...C. For complaints and grievances requiring patient follow-up, Patient Experience may communicate decisions and outcomes via phone or letter."

Review of facility policy #TM7XN2FTXHRM-3-206, last revised 9/27/2022, titled, "Patient Bill of Rights and Responsibilities Policy," revealed, " Patient Complaint:...Information written by patients on satisfaction surveys are generally considered complaints unless the patient attaches a written letter to the survey form or raises a quality of care issue (issue would then be considered a grievance).

On 10/24/2023 at 1:20 PM in an interview with Staff B, when asked what happens when a patient submits their contact information on a post hospitalization survey, Staff B stated, "If we have contact information we will follow up, we call them back and tell them what was done whether a grievance or a complaint. If there is no contact information then we look for trending. Both are reported to leadership and share the patient experience information."

On 10/25/2023 at 8:15 AM in an interview with Director of Pt. Experience P, when asked what is the process for managing patient survey responses, Staff P stated, "We look for trigger words- and monitor trends, if they leave contact information, we follow up. Every manager sees the feedback specific for their unit. If they don't give us contact information we respect their privacy."

On 10/25/2023 at 1:05 PM Staff B stated, "(Staff P) found the comment from (Pt. #1) in a hot comments report and is printing it for you." When asked why wasn't this discovered earlier, B stated, "We're trying to figure out what happened with running our reports." When asked if it was correct that no response had been given to (Pt. #1), B stated, "Correct, there has been no response."

On 10/25/2023 at 1:10 PM review of Pt. #1's survey response, received date of 07/17/2023 revealed the concerns Pt. #1 had and (his/her) contact information requesting a response.

On 10/25/2023 at 1:15 PM Chief Nursing Officer J stated, "We will correct that."