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1593 EAST POLSTON AVENUE

POST FALLS, ID 83854

PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES

Tag No.: A0120

Based on hospital policy review, patients rights information review, and staff interview, it was determined the hospital failed to ensure a process for referral of patient care concerns to their QIO. This had the potential for unresolved patient issues regarding patients' quality of care or premature discharge. Findings include:

A hospital policy, "Concerns, Complaints, & Grievances," revised August 2020, was reviewed. The policy did not include a mechanism for for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate QIO.

Hospital patient rights information was reviewed. Reference to the hospital's QIO, Kepro, or how to contact them, was not included in the patient rights information. It was unclear how patients and/or their representatives were informed how they could contact the hospital's QIO for concerns regarding quality of care or premature discharge.

The Director of Quality was interviewed on 11/04/20, beginning at 1:23 PM, and the hospital's grievance policy and patient rights information was reviewed in her presence. She stated she was unaware the hospital's QIO information had to be included as part of the grievance process. The Director of Quality stated the information would be added to the hospital's grievance policy and patient rights information.

The hospital failed to ensure a process for referral of patient care concerns to their QIO.

PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION

Tag No.: A0123

Based on hospital policy review, grievance documentation review, and staff interview, it was determined the hospital failed to provide written grievance resolutions which included investigative steps and/or completion dates for 4 of 4 patients (#2 - #5) whose grievance responses were reviewed. This had the potential for incomplete grievance investigations and resolutions communicated to patients. Findings include:

A hospital policy, "Concerns, Complaints, & Grievances," revised August 2020, was reviewed. The policy did not include language regarding the inclusion of written dates of completion of grievances to complainants. Additionally, the policy stated, "At each and every thirty day period that the grievance has not been resolved, the patient/representative shall be informed of the actions taken to address the grievance...". This policy was not followed. Examples include:

1. Patient #2's grievance response letter was reviewed. The response letter did not include investigative steps taken by the hospital in addressing Patient #2's grievance. Additionally, the response letter did not include the date the grievance was completed.

2. Patient #3's grievance response letter was reviewed. The response letter did not include investigative steps taken by the hospital in addressing Patient #3's grievance. Additionally, the response letter did not include the date the grievance was completed.

3. Patient #4's grievance response letter was reviewed. The response letter did not include the date the grievance was completed.

4. Patient #5's grievance response letter was reviewed. The response letter did not include investigative steps taken by the hospital in addressing Patient #5's grievance. Additionally, the response letter did not include the date the grievance was completed.

The Director of Quality was interviewed on 11/04/20, beginning at 10:35 AM, and the patients' grievance response letters were reviewed in her presence. She confirmed the hospital's grievance policy was incomplete. Additionally, the Director of Quality confirmed not all patient grievance response letters included the investigative steps taken to address the grievance.

Patient grievance response letters were incomplete.