HospitalInspections.org

Based on policy review, medical record review, and interviews the hospital failed to inform the patient or the patient's representative on whom to contact to file a grievance, the steps taken on behalf of the patient to investigate an alleged incident, the results of the investigation and the date of completion for one (Patient 1) of seven patients reviewed. This deficient practice has the potential to infringe on the rights of all patients or their representatives to have their concerns heard and properly investigated through the grievance process.

Findings Include:

Review of facility policy titled "Patient Complaints/grievances" reviewed date 09/2023 showed PURPOSE: To ensure that all patient complaints and or grievances are addressed in a timely, reasonable, and consistent manner in compliance with Joint Commission and Centers for Medicare and Medicaid Services (CMS) standards and regulations. This policy provides a mechanism for initiation, review and when possible, resolution of patient complaints or grievances concerning the quality of care or services rendered.
Sequence of Steps:

A. Grievance Management:

The hospital employee receiving the information will:

1. Enter a report of the information into the patient complaint/grievance database and 2. Forward the report via the database email function to the Director of Risk Management and to the Director of the involved department(s). More involved patient concerns are forwarded immediately to the department in which the concern involves or the House Supervisor after hours.

The Director/Manager or House Supervisor will:

1. Investigate and act as appropriate to resolve the concern.
a. Discuss the concern with the patient.
b. Interview staff involved.
c. Act as applicable to resolve the issue.
2. Keep the patient informed of what actions are being taken towards the resolution of their problem.
3. Document the concern, investigation, and resolution in the Patient Complaint/Grievance database.
4. If resolution is not attained, see the procedure for unresolved concerns below.
5. All grievances will be handled as quickly as possible; generally review, investigation and resolution will occur within ten (10) working days. This process for any grievance alleging abuse or neglect will be initiated immediately upon receipt.


Patient 1


Review of Patient 1's discharged medical records showed an 85-year-old patient admitted with chief complaint of rapid heart rate and an admitting diagnosis of atrial flutter with palpitations, chronic cough, elevated brain natriuretic peptide (BNP - a blood test that indicates heart failure) level, and generalized muscle weakness.


During an interview on 11/14/23 at 11:12 AM Patient 1's daughter stated, "When I reported the incident of a staff member slapping my mother's hand away from her meal tray to [Staff L, RN] nurse manager and the night shift charge nurse, I was not informed that I could file a complaint or grievance." Patient 1's daughter stated that staff did voice concern about the complaint but did not do anything to change the situation. Patient 1's daughter stated, "Supposedly they were going to remove that person from my mother's care, but I don't know if the facility did that."


During an interview on 11/14/23 at 3:30 PM, Staff C, RN stated that there was an incident with Patient 1 and her meal tray involving a dietary aide. Staff C stated that the dietary worker brought the tray in, and the patient tried to grab it. The dietary worker yanked the meal tray back from Patient 1. Staff C stated that she called Staff O, RN, Director of Nursing (DON) regarding the incident, and she came up and immediately spoke with the Patient 1's daughter. Staff C stated that the nurse manager was going to file an incident or grievance report. Staff C stated that after talking with Patient 1's daughter the DON removed the dietary worker from the situation and told her not come to Patient 1's room anymore.


During an interview on 11/15/23 at 12:06 PM with Staff L, Nurse Manager, stated, "My DON [Staff O] who no longer works at the facility, spoke with Patient 1's daughter." Staff O stated that Patient 1's daughter reported that a staff member slapped her mother's hand. Staff O talked with Staff N Dietary aide who was accused of either slapping or grabbing Patient 1's hand to keep the patient from eating. Staff L stated that Staff N said that she went to grab her hand, so the patient wouldn't touch the hot plate. Staff L stated, "As far as I know [Staff O] told me she put in a verge (incident report) and from what I understand the dietary aide was instructed not to go back into Patient 1's room."


During an interview on 11/15/23 at 12:16 PM, Staff N Dietary Aide and Staff M Dietary Manager stated, "my diet clerks told me about the incident first then I got a verbal report from [Staff O, DON] regarding the incident." Staff M stated, "I was waiting for any verge or incident report regarding Patient 1, but I never received one." Staff M stated, "I completed reeducation and training with Staff N, but it was informal because I did not hear anything from human resources (HR) that it was a serious incident that should be handled more formal." Staff N stated, "Oh no I am never going to hurt somebody." when asked about slapping or shoving Patient 1's hand away.


Review of complaints, grievances and incident log dated 09/2023 to 10/2023 failed to show a report of any staff member allegedly slapping or pushing a patient hand away from their meal tray.