HospitalInspections.org

Based on record review and interview, the hospital failed to provide a written notice of grievance resolution to the patient representative for 1 of 1 patient (#1) with a grievance in a total sample of 3 patients.

Findings:

Review of the hospital's Grievance Policy revised 03/03/21 revealed, in part, the following:
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 resolution, requires investigation, and/or requires further action for resolution, then the complaint is a grievance.
Whenever the patient or the patient's representative requests their complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, then the complaint is a grievance.
Procedure:
...4. A written response, acknowledgement of receipt, will be sent to the patient or their representative after a grievance has been submitted for review....
6. Upon completion of the investigation, the hospital will, within the parameters permitted by law and regulation, provide the patient with a written notice of the medical center's determination regarding the grievance, including the name of the facility, contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. A grievance will be considered resolved when the patient is satisfied with the actions taken on their behalf.

Review of the medical record for Patient #1 revealed she presented to the Emergency Department on 12/18/23 at 18:57 by ambulance from a local nursing home. On 12/19/23 at 07:30, she was found on the floor of her room in the Emergency Department. Review of the record revealed no documented evidence that the patient's family was notified of the fall.

On 01/23/24 at 2:15pm, during review of the medical record for patient #1, an interview with S1ED Director confirmed there was no documentation in the medical record that the patient's responsible party was notified of the patient's fall in the ED on 12/19/23. She further revealed that she had a phone conversation later in the day on 12/19/23 with S2 Patient Advocate and the patient's daughter, who had called the hospital with concerns about how the patient had fallen and that she had not been notified.

On 01/24/24 at 12:45pm, an interview with S2Patient Advocate, revealed she had received a phone call from the daughter of Patient #1 on 12/19/23, sometime after she was transferred from ED to the telemetry floor. The daughter was very upset about the fall in the ED that morning and that she had not been notified. The daughter also stated that she wanted to know how the fall happened.

Review of the Grievance Log revealed no evidence that the complaint received by the daughter of Patient #1 had been investigated as a grievance.

S2Patient Advocate confirmed that she noted the daughter's concerns, consulted with S1ED Director, and the two of them called the daughter back later that day to discuss the situation with her. She confirmed she did not consider the complaint to be a grievance, but confirmed it was a complaint that required an investigation and follow-up with the daughter prior to resolution, as noted in the hospital's grievance policy. She further confirmed that she did not provide a written notice to the daughter to acknowledge the complaint or the resolution after the investigation was complete.