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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0118 - The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to have a system in place to ensure patients' concerns were acknowledged, investigated and resolved in accordance with the facility's grievance process.

Based on interviews and document review, the facility failed to ensure patients' concerns were being acknowledged, investigated and resolved in accordance with the facility's grievance process.

This failure created the potential for grievances to go unaddressed and allowed for deviation from the facility's approved grievance process.

FINDINGS

POLICY

According to Patient and Family Complaints/Grievances, a grievance is a written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations.

All written letters, e-mails or faxes from patients or their representative; any patient response as a result of a patient satisfaction survey requesting feedback and a resolution will be considered a grievance. Whether these grievances are from an inpatient or outpatient, released/discharged patient regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs, these will all follow the grievance process.

If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint will be considered a grievance.

The hospital or Patient Advocate must provide a written response to each patient's grievance. The written response will include: the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the investigation, which includes adequate information to address each item stated in the grievance, the date of the completion of the grievance process.

If the complainant is not satisfied with the results of the initial grievance investigation, the complainant shall be informed via the written response that upon request, the Patient Care Representative or Patient Advocate will either: forward the grievance to the administrative officer or such officer's designee for a Second Level Review or forward the grievance and the facility findings in writing to the Colorado Department of Public Health and Environment, or forward the grievance to the Medical Director or operational group administrator for a Second Level Review.

If the complainant is not satisfied with the results of the initial grievance investigation, the complainant shall also be informed via written response that they can also refer the matter directly to The Health Facilities Division of the Colorado Department of Public Health and Environment or The Joint Commission.

1. The facility failed to have a system in place to ensure all interactions from patients or patient representatives regarding patient care concerns were addressed in accordance with the facility's grievance process.

a) A review of the facility's complaints and grievance logs was conducted and revealed the following:

Review of the Complaints and Grievances Log from 05/01/16 to 12/26/16 revealed a total of 188 entries which included 6 documented as grievances and 182 documented as complaints.

Review of the "Bridge Report Complaints and Grievances" log from 05/01/16 to 12/26/16 revealed a total of 28 entries which included 3 documented as grievances and 25 documented as complaints. The 3 documented grievances in the Bridge Report Log were in addition to the 6 documented grievances listed in the Complaints and Grievances log, resulting in 9 total grievances documented between 05/01/16 and 12/26/16.

b) On 12/29/16 at 11:45 a.m., the Patient Relations Coordinator (PRC #1) provided a stack of documents. PRC #1 stated the documents consisted of his/her documentation of correspondence and investigative work for all patient or patient representative complaints and grievances from 04/01/16 to 12/29/16. Review of the documents revealed 105 total patient or patient representative concerns.

24 of the 105 concerns were not listed in the Complaints and Grievance Log.

7 of the 105 concerns were initiated by a letter or email from a patient or patient representative; however, 3 of the 7 were documented as complaints on the Complaints and Grievance Log and the remaining 4 were not found in the log. This was in contrast to the policy which stated all written letters or e-mails from patients or their representative would be considered a grievance.

87 of the 105 concerns revealed they took longer than one day to investigate; however, none of those 87 concerns were documented as grievances on the Complaints and Grievance Log. This was in contrast to the policy which stated if a verbal patient care complaint could not be resolved at the time of the complaint by staff present then the complaint was considered a grievance.

62 of the 105 concerns showed evidence of other staff involvement to investigate the concern; however, none of those 62 concerns were documented as grievances on the Complaints and Grievance Log. This was in contrast to the policy which stated if a verbal patient care complaint was referred to other staff for later resolution and/or required investigation then the complaint was considered a grievance.

76 of the 105 concerns revealed they were initiated after the patient was discharged; however, none of those 75 concerns were documented as grievances on the Complaints and Grievances Log. This was in contrast to the policy which stated if a verbal patient care complaint could not be resolved at the time of the complaint by staff present then the complaint was considered a grievance.

Further review of PRC #1's documentation revealed several of the 105 patient or patient representative concerns involved concerns with patient care; however, only 1 of the 105 concerns was documented as a grievance on the Complaints and Grievance Log. This was in contrast to the policy which defined a grievance as a written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care.

Examples of patient care concerns reviewed in PRC #1's documentation included:

i) Patient A reported concerns on 10/14/16 regarding a visit to the Emergency Department (ED) on 10/13/16. Patient A reported a vital sign machine was alarming for 30 minutes before it was attended to. Also, Patient A reported a nurse left a bottle of Dilaudid (intravenous pain medication) and a syringe on the counter of his/her room. In addition, Patient A reported after leaving the ED s/he continued to vomit for hours and no one had given him/her anti-nausea medication as s/he had requested.

Further documentation revealed on 10/18/16 a staff member reviewed Patient A's medical record and documented s/he had included an educator to help provide education and met with the staff member to review narcotic wasting process policy. On 10/20/16 at 12:50 p.m., a voicemail was left with Patient A. On 11/02/16 Patient A called back and documentation stated "we discussed findings". There was no evidence of a documented written response sent to Patient A regarding what the findings were or where Patient A could forward his/her concerns if s/he was unsatisfied with the results.

Patient A was listed on the Complaints and Grievances Log as a complaint with the investigation complete and unknown resolution. This was in contrast to the facility's policy which stated a grievance is a written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care.

ii) The spouse of Patient B reported several concerns on 09/16/16 regarding a recent hospitalization. Patient B's discharge was documented on 09/13/16, 3 days before the concerns were reported. The spouse's concerns included the allegation of no nurse assessment conducted upon admission, no oral care, no dressing changes, and that the patient was not turned.

Further documentation stated the complainant was "unhappy with leadership interaction and lack of resolution with concerns". On 09/27/16 a call was attempted and a voice mail message was left. Documentation on 10/13/16 stated PRC #1 called Patient B's spouse again and "was able to review findings. [S/he] is satisfied." There was no evidence of a documented written response sent to Patient A regarding what the findings were or where Patient A could forward his/her concerns if s/he was unsatisfied with the results.

Patient B was listed on the Complaints and Grievances Log as a resolved complaint. This was in contrast to the facility's policy.

iii) Patient C reported concerns on 07/25/16 regarding a hospitalization from 03/01/16 to 03/03/16. Patient C's concerns included being turned poorly causing pain, the bedside commode not being emptied after each use, poor perineal hygiene care performed by nurses and oxygen tubing not long enough for the patient to get to the bathroom.

Documentation on 08/11/16 revealed PRC #1 called Patient C and the patient asked if the PRC could call back the next day as s/he was at a luncheon. No further calls or written correspondence was documented in the report showing evidence the complainant had been notified of the results of the investigation.

In addition, Patient C was not listed in the Complaints and Grievances Log. This was in contrast to the facility's policy.

c) On 12/29/16 at 11:45 a.m., PRC #1 provided a stack of hand written notes. PRC #1 stated the stack consisted of his/her Phone Log which documented all phone calls received on the patient complaint phone line from 04/01/16 to 12/26/16. Review of the Phone Log revealed approximately 840 phone calls documented by PRC #1. Several of the approximated 840 phone call entries involved calls from patients or patient representatives with concerns of patient care or staff behavior. Examples included:

i) Documentation on 05/12/16 at 10:34 a.m. revealed Patient D called to report concerns. The documentation stated Patient D was admitted on Tuesday and was humiliated, discriminated and called "drunk" in front of his/her sister and niece. No further documentation was found regarding what was done to acknowledge, investigate or respond to Patient D's concerns. In addition, Patient D was not listed in the Complaints and Grievances Log.

ii) Documentation on 07/07/16 revealed Patient E called two times to report concerns. The documentation stated Patient E was thrown down by security and was thrown out of the ED. Further documentation reported Patient E was called and a voice mail message was left on 07/07/16 at 12:05 p.m. No further documentation was found regarding additional attempts to reach Patient E or what was done to acknowledge, investigate or respond to Patient E's concerns. In addition, Patient E was not listed in the Complaints and Grievances Log.

iii) Documentation on 09/12/16 revealed Patient F called to report concerns regarding a visit to the ED on 09/07/16 with a dog bite. The documentation revealed the patient reported s/he was "allergic to antibiotics, told triage nurses and 3 other folks - can take sulfa - had reaction." Documentation next to Patient F's name stated a voice mail message was left with the patient. No further documentation was found regarding additional attempts to reach Patient F or what was done to acknowledge, investigate or respond to Patient E's concerns.

Review of the Complaints and Grievances Log revealed Patient F was listed as a complaint entered on 09/15/16 for a medication administration issue that occurred on 09/01/16. Further documentation on the log listed the complaint's investigation as completed and closed on 10/20/16 with an unknown resolution.

iv) The spouse of Patient #6 was documented in the Phone Log 3 times. The first phone call was documented on 05/16/16 at 1:49 p.m., which stated the spouse "wants medical record - will send form." The second phone call was documented on 05/17/16 at 8:27 a.m., which stated "[spouse's] death - wants someone to review medical record with him/her." The third phone call was documented on 06/13/16 at 11:27 a.m. which stated "5/1 - 5/10 medical records, 30' EPIC - Called (unknown name), s/he called the spouse and will get EPIC records sent". No further documentation was found regarding what was done to acknowledge, investigate or respond to Patient #6's concerns. In addition, Patient #6 was not listed in the Complaints and Grievances Log.

v) Patient #8 was documented in the Phone Log on 12/01/16. The only documentation noted after Patient #8's name was a question mark and a phone number. No further documentation was found regarding an attempt to contact Patient #8 or what was done to acknowledge, investigate or respond to Patient #8's concerns. In addition, Patient #8 was listed in the Complaints and Grievances log with a resolved complaint closed on 10/14/16, 49 days prior to Patient #8's call on 12/01/16.

A review of a Patient Relations Worksheet for Patient #8 was conducted and revealed that Patient #8 spoke with PRC #1 on 10/04/16 regarding concerns from a visit to the ED on 10/03/16. Patient #8 reported s/he was directed to come to the ED by his/her psychologist for a medication evaluation. Patient #8 then reported s/he was locked up against his/her will, all items were taken away from him/her, and that s/he was locked up and placed in a paper gown. Patient #8 also reported reading lips of staff having a conversation in the Nursing Station saying the patient was crazy and pacing. Patient #8 further reported s/he demanded to leave after 4 hours and no medication adjustment was made.

On 10/14/16 at 10:40 a.m., PRC #1 documented that s/he called Patient #8 and "reviewed the plan to re-evaluate process going forward. Patient stated s/he was satisfied with plan."

On 10/14/16 at 11:57 a.m., PRC #1 documented the case was reviewed with the Director of the ED and with the Regulatory Program Manager. PRC #1 then documented s/he would review with the Assistant Chief Nursing Officer (ACNO) when s/he returned the following week. No further documentation was found regarding if the ACNO was notified of the case.
Patient #8's concerns were documented on the Patient Relations Worksheet as a resolved complaint with a closure date of 10/14/16. This was in contrast to the policy which stated if a verbal patient care complaint could not be resolved at the time of the complaint by staff present, was postponed for later resolution, was referred to other staff for later resolution, required investigation, and/or required further actions for resolution, then the complaint would be considered a grievance. This resulted in Patient #8's concerns to be unaddressed in accordance to the grievance process.

d) On 12/29/16 at 10:37 a.m., an interview was conducted with the Patient Relations Coordinator (PRC #1) who revealed s/he was the only PRC employed at the facility and that s/he reported to the Manager of Patient Safety. PRC #1 confirmed the facility had 9 grievances from May of 2016 to December of 2016.

PRC #1 then recalled interacting with Patient #8 regarding his/her concerns. PRC #1 stated Patient #8 presented to the ED for a psychiatric medication adjustment but the ED did not provide that service. PRC #1 then stated s/he recalled Patient #8 reporting s/he could see staff members mouthing words like s/he's crazy, s/he's pacing' but PRC #1 did not consider that to be a care issue. PRC #1 stated Patient #8's concerns were entered as a complaint and not a grievance because according to his/her understanding of the Centers for Medicare and Medicaid Services (CMS) regulations, Patient #8's concerns did not meet the level of a grievance. PRC #1 then stated s/he was unable to provide which regulations s/he was referring to and using as guidance for determining if concerns were considered to be at the level of a grievance.

e) After reviewing the documentation and Phone Log provided by PRC #1 on 12/29/16 at 11:45 a.m., a second interview was conducted with PRC #1 on 12/29/16 at 2:10 p.m. The Director of Quality and Patient Safety (Director #2) was present during the interview. PRC #1 reviewed the entry on the Phone Log regarding a call from Patient #8 on 12/01/16. PRC #1 stated since the entry was crossed out, that meant s/he had returned the call. PRC #1 then stated s/he could not remember why Patient #8 had called again or what they had talked about, but if s/he thought the call required the complaint to be reopened s/he would have reopened it.

PRC #1 then reviewed the entry on the Phone Log from Patient #6's spouse on 05/17/16 regarding his/her spouse's death and requesting someone to review the medical record with him/her. PRC #1 stated s/he received guidance from the former Chief Medical Officer (CMO) and was told to have Patient #6's spouse talk with either Patient #6's Primary Care Physician (PCP) or the spouse's PCP in order to have an objective opinion of Patient #6's medical record. PRC #1 stated s/he did not document either the discussion with the former CMO or the follow up phone call with Patient #6.

f) On 12/29/16 at 12:49 p.m. an interview was conducted with the Manager of Patient Safety (Manager #3) who stated his/her job responsibilities included conducting safety huddles with staff, reviewing the facility's complaints and grievances, and conducting performance improvement projects. Manager #3 stated s/he was not currently working on any performance improvement projects in the grievances and complaints department because there was no need at this time. Manager #3 stated his/her role in the complaints and grievances department involved meeting weekly with PRC #1 to discuss what s/he was working on. Manager #3 stated s/he became PRC #1's boss 3 weeks ago and had not conducted any reviews or audits of PRC #1's complaints and grievances documentation or Phone Log. When asked how Manager #3 ensured PRC #1 was performing the required job requirements, Manager #3 stated s/he did not micro manage his/her staff and that s/he reviewed PRC #1's work by sitting down and talking with him/her.