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Tag No.: A0118
Based on review of hospital policies, grievance and complaint documents, and interviews, the hospital failed to ensure the grievance policy was implemented for One (Patient #20) of one patient.
This failed practice has the likelihood to result in the hospital failing to investigate and resolve patient or family complaints of abuse, neglect, patient harm, or substandard care.
Findings:
Review of the hospital's complaint and grievance documents did not show the hospital had a complaint/grievance log or other organized process to collect and process patient complaints and grievances. The hospital was not collecting information that identified patients with complaints and grievances. Hospital grievance documents lacked unique patient identifiers, and did not show the hospital investigated, and resolved patient's grievances.
Review of the hospital's complaint and grievance documents did not show the hospital investigated or resolved the grievance of One (Patient 20) of one patient.
Review of the hospital Policy titled "Patient Grievance Process Medical Surgical Unit (07/2011)", showed that all grievances receive immediate priority and must be investigated within 24 hours.
On 5/22/19 at 10:55 am, Staff G stated the hospital's policy titled "Patient Grievance Process Medical Surgical Unit (07/2011)", was not being followed. He/She stated the grievance form, titled "Grievance Management Form" was not being used. He/She stated that each hospital manager investigates complaints and grievances. Staff G stated the hospital did not have a grievance log.
On 5/23/19 at 12:20 pm, the family member of Patient #20 stated that he/she had contacted the hospital five times between the dates, 01/01/19 and 1/10/19, in an attempt to file a grievance on behalf of Patient 20. The family member of Patient #20 stated that he/she did not receive an investigation report from the hospital concerning the grievance.
* In a phone call, on 01/02/19, Staff H told the family member the hospital would investigate Patient #20's fall.
* On 01/04/19 the family member sent an e-mail to the hospital which was not responded to.
* On 01/07/19 the family member left a voice message with the hospital's business number that was not responded to.
* On 01/08/19 attempted to contact Staff G and left a voice mail.
* In a phone call 01/09/19 Staff G told the family member the hospital was still investigating Patient #20's fall.
Tag No.: A0123
Based on review of hospital policies, hospital grievance and complaint documents, and interviews, the hospital failed to provide written responses to grievances.
This failed practice resulted in no grievance investigation, written response, or resolution for one (Patient 20) of one patient, and has the likelihood to result in the hospital failing to investigate and resolve patient or family complaints of abuse, neglect, patient harm, or substandard care.
Findings:
Review of the hospital Policy titled "Patient Grievance Process Medical Surgical Unit (07/2011)", showed that the hospital would provide the patient with the name of the Grievance Coordinator, the steps taken to investigate and resolve the grievance, the final result of the grievance, and the date of grievance completion, in writing. The policy stated that information would be sufficient to identify the individual making the complaint, the date of receipt, the nature of the complaint, the patient's attending physician, and the hospital location should be documented.
Review of the hospital's complaint and grievance documents showed no written documentation with notice of its decision, the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, or the date of completion, was provided to Patient #20
On 5/22/19 at 10:55 am, Staff G stated that information the hospital had been collecting was not adequate to investigate complaints, there was no centralized log and, the hospital grievance documents did not follow the hospital's policy for collecting and documenting information for patient complaints and grievances.