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Based on record review and interview the facility failed to investigate and respond to a complaint that was called in, via telephone, to Risk Management. Findings:


Review of the online complaint, submitted to the State Agency on 12/29/17, revealed the complainant had made several calls to the hospital on 9/29/17 and left messages with Risk Management. The complainant received a return call from the Patient Safety Director (PSD) on 10/3/17. The complainant stated the PSD told her she would take the information and "report it as a complaint and it would be reviewed by risk management staff, nursing leadership," and that family member "would receive a call back to discuss further with me and/or the POA [Power of Attorney]. The complainant stated "I never received a return call and the POA was never contacted."


Patient #1 was admitted on 9/23/17 with diagnosis of acute hypoxic respiratory failure; shock and pneumonia.


Record review of the "Patient Compliant/Grievance Log" from 9/1/17 to 1/28/18 revealed no documentation of the complaint that was called in regarding Patient #1.


On 2/1/18 at 9:50 am an interview with Patient #1's family revealed no one in the family had received any information or follow up regarding the complaint filed.


During an interview with Patient Safety Director on 2/1/18 at 10:05 am she stated "I do not remember that phone call at all." In addition she confirmed that the complaint was not included on the grievance log, the complaint was not investigated, and no written or verbal response to the grievance was given to the complainant.


Review of the facility's policy "Patient Complaints/Grievances, Handling and Resolution of, last updated August 2016 revealed: " ...5. Upon receipt of a grievance, the Chief Patient Safety Officer shall confer with the appropriate Department Director as soon as possible, to review, investigate and resolve with the patient and/or patient representative within 7 working days ..." and " ...6. If the grievance will not be resolved immediately, or if the investigation will not be completed within 7 working days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days." And " ...4. In response to grievances, the hospital shall provide the complainant with written notice of its decision and grievance resolution."

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