HospitalInspections.org

Based on document review and interview, the facility failed to inform the complainant a plan of action with timeframes to review the grievance and a provision of a written response to a grievance for 1 of 1 grievances reviewed. (Family member #1)

Findings include;

1. Facility policy titled "Patient Complaint and Grievance Management Policy" last reviewed/revised 10/24/18 indicated the following: " ...POLICY/PROCEDURE:...respects a patient's right to submit a formal complaint or grievance, expect that it will be addressed in a reasonable timeframe, and be provided with results of the follow up on that complaint or grievance...3. General Clarification Regarding Grievances: A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided...or the hospital's compliance with Medicare's related Conditions of Participation. For the purposes of this requirement, an email or fax is considered "written" and is included as a grievance...II. GENERAL PROCEDURES FOR HANDLING PATIENT/CLIENT/VISITOR COMPLAINTS: ...B. Any alleged HIPAA [Health Insurance Portability and Accountability Act] violations should be reported directly to...Privacy Officer...The electronic incident/complaint reporting system should be utilized to document the investigation and findings of the allegation(s)...V. Hospitals Only - Grievance Processes: ...C. All patient grievances will be reviewed, investigated and resolved as soon as possible...2. It is anticipated that most grievances can be resolved and the resolution communicated in written format within 7 days of the initial receipt date of the grievance. However, some grievances are more complex and may need additional time to review and follow up. In those situations where a resolution cannot be provided in that time frame, a written explanation will be forwarded to the patient in which it will include reasons for the delay and the date when the resolution is expected to occur. 3. The final written response will include the substance of the grievance, the steps taken to investigate the grievance, the results of the investigation and the date of completion. This response will also include the Hospital representative's name and telephone number who completed the resolution processes. 4. Documentation relating to the grievance will be maintained in the electronic incident/complaint reporting system..."

2. A review of a grievance form titled "Event Summary with all Tasks" related to patient #1, indicated a written grievance related to a privacy issue was received on 1/27/20 at 2:18 a.m. from Family Member #1. The grievance was categorized as a HIPAA: Privacy/Security (Inappropriate Information Disclosure) and reported by A10, Director of Intensive Care Unit and Emergency Care Center on 1/27/20 at 11:45 a.m.

A note dated 1/27/20 at 11:45 a.m. indicated the following: "...Complaint Investigation...Assigned to [A10]...From Sender: A complaint requires your investigation....Cause Category: Communication Issue. Cause Notes: [1/27/20 at 3:50 p.m. by A10] Follow up to [Family Member#1] on 1/27/20 after our telephone discussion. Actions Taken: Education/Training (Staff). Actions Notes: [1/27/20 at 3:54 p.m. A10] made Medical Chief aware..."

A note dated 1/29/20 at 9:55 a.m. by A6 (Risk Manager) indicated the following: "... ***CATEGORY/SUB-CATEGORY CHANGED***...From Sender: This task was automatically created when a user changed the category or sub-category of an event...Old Classification: Complaint Event, Verbal Complaint, No Injury/Adverse Reaction. New Classification: HIPAA: Privacy/Security Event, Inappropriate Information Disclosure, Not Applicable..."

A note dated 1/29/20 at 9:55 a.m. by A6 indicated the following: "...FYI [For Your Information] with confirmation...Assigned to [A17, Privacy Officer]...From sender: Please review this event FYI. Please note in the box below that you have reviewed the event--then, click on Save and Close..."

A note dated 1/29/20 at 10:54 a.m. by A17 indicated the following: "...Closed by [A17]...Response: Acknowledged. Any privacy follow up that needs to be done will be documented in the Fair Warning auditing system..."

A note dated 1/29/20 at 12:07 p.m. by A6 indicated the following: "...Risk Closure...Assigned to [A6]..."

The event form lacked documentation of Family Member #1 being informed of a plan of action with timeframes to review the grievance and a provision of a written response.

3. During an interview with A17 on 3/5/20 at 1:49 p.m., he/she verified the complaint/grievance from Family Member #1 related to Patient #1 on 1/27/20. He/she verified that complaint/grievance was considered a privacy complaint/grievance on 1/29/20 and not a patient care complaint/grievance as initially thought. So when the category was changed an email was sent out to A17 and A18 (Executive Director of Health Information Management) since it was considered a privacy concern. A17 verified that he/she acknowledged the privacy complaint/grievance on 1/29/20 at 10:54 a.m. A17 verified that he/she hit the wrong button on the Events Management System to extend the dates for follow-up so that the system would prompt him/her daily that the concern needed follow up instead he/she hit the save and complete button, so then he/she was not notified of the concern daily as a reminder to follow up on it and to keep track of it. A17 verified that up until 3/5/20 no follow-up investigation was completed. A17 verified that no letter was sent out to Family Member #1 of Patient #1. A17 also verified that privacy would also follow the facility's complaints/grievances policy and procedure.

4. During an interview with A10 on 3/5/20 at 3:34 p.m., A10 verified that he/she had received an email from Family Member #1 related to Patient #1. A10 verified that he/she had spoken via telephone to Family Member #1 as a follow-up conversation to his/her concerns on 1/27/20. A10 verified that he/she had asked for clarification from Family Member #1 on who the physician was in the complaint/grievance, as no physician name was mentioned in the complaint/grievance. A10 verified that Family Member #1 told him/her that it was an Emergency Department Physician and was unable to provide a physician's name. A10 verified that he/she then followed up by notifying MD3 (Chief Medical Officer for the Emergency Care Center) of Family Member #1's complaint/grievance related to privacy. A10 then verified that he/she had sent an email to Family Member #1 on 1/27/20 at 3:50 p.m.

5. During an interview with A3 (Safety and Accreditation Coordinator) on 3/5/20 at 3:53 p.m., he/she verified that the complaint/grievance related to the Emergency Care Center Physician did not go to peer review.

6. During an interview with A6 on 3/5/20 at 4:02 p.m., he/she verified that an initial discussion was completed with Family Member #1 on 1/27/20 related to the complaint/grievance, the Chief Medical Officer for the Emergency Care Center was notified and after that no additional information related to the complaint/grievance was documented.