HospitalInspections.org

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure that the policy and procedure for grievance resolution, is implemented.

Findings include:

Reference: Facility policy titled, "Complaint/Compliment Management" (effective 04/18/2023) states, " ... Definitions: ... Grievance: any written complaint by a patient, or the patient's representative, regarding the patient's care, abuse, or neglect ... Procedure: ...C. Patient Grievances (Written and Verbal Complaints): ... 5. A written letter of response will be prepared for all grievances regarding discrimination based upon disability, quality of care ... including but not limited to: ... c. Alleged negligence ... 6. Written letters of response must include the following: a. the name of the hospital or practice contact person, b. the steps taken on behalf of the patient to review the grievance, c. the results of the grievance process, d. the date of completion. 7. ... A letter of response will be coordinated by the Patient Relations Manager with Department and/or Practice Manager input. The Patient Relations Manager or a Risk Manager must approve the draft response before it is placed in final form. ... ."

On 11/20/23, a review of the facility's Grievance Log for 2023 was completed in the presence of Staff #1 (S1), Risk Manager.

On 9/15/23, a grievance (Event #: 23063551) was filed on behalf of Patient #1 (P1). The grievance stated, "Call from (guardian) ... One of [his/her] wards was discharged on 9/15/2023. Per (guardian), when the group home came to pick up the patient, they noticed the patient had a black eye. (Guardian) questions why no one called [him/her] to alert [him/her] of this ... (Guardian) would like a call back. Message left 9/15 at 5:15."

On 09/18/23 at 2:06 PM, a response was sent via email from Staff #5 (S5), Director of Risk Management and Patient Relations. The email stated, " ... Here is the screenshot. You can see the date and time - 9/11/2023 at 1941 which is 7:41 pm. Right eye - and if you go to the red box on the right it specifies hematoma to right upper eyelid. Please let me know if you require anything further. Thanks." The grievance log indicated that the grievance (Event #: 23063551) was "Closed" (no date).

On 11/20/2023 at 12:30 PM, S1 confirmed that the email sent by S5 was the facility's grievance response for event #: 23063551. S1 confirmed no formal letter of resolution was written in response to the grievance, as per facility policy.