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Based on record review and interview, facility staff present at the time of a verbal complaint reported by a patient's caregiver failed to refer information to other appropriate staff for later resolution, investigation, and/or further actions for resolution for 1 (#11) of 12 (#1-#12) records reviewed.

Review of record #11 with Admission Date of 07/26/24, revealed a diagnosis of Seizures, Acute Encephalopathy, Fractured Left Humerus and history of Alzheimer's Disease. The pateint was initially to be discharged to a Skilled Nursing Facility on 07/31/24, but later was discharged home in the care of his wife.

Review of the "Case Management Progress Note" for 07/31/24 at 13:34 (1:34 PM) indicated a discharge order was received and the van from the Skilled Nursing Facility would arrive to transport the patient at 3:15 PM.

Further review of a "Care Plan and Interdisciplinary Update" note indicated a Behavioral Emergency Response Team (BERT) call was initiated at 1547 (3:47 PM). The "Behavioral Health Progress Note" stated, "BERT Call @1547 Patient was in the process of being transported to a SNF when the patient's wife reportedly misunderstood how the patient was being handled and became aggressive and combative with staff and with the representative from the SNF. This reportedly angered the patient who became combative and aggressive as well. Patient's wife reported she believes both her and her husband were assaulted by the ASJMC staff. The SNF representative cancel the transfer and refused to accept the patient. After a long while, the patient was discharged in the care of his wife and left the building without further incident".

A Case Management Note of 07/31/24 indicated the Spouse stated she planned to take the pateint home and the Case Manager notified the Physician of the plan to discharge home. The discharge order was received and the patient was discharge to home without incident.

Review of the faciliity's Patient Complaint and Grievance Policy stated, "All associates will be alert to expressions of dissatisfaction by patients or their representatives and attempt to proactively address their concerns before the issue becomes a complaint or
grievance". "Complaints may be received by any associate and should be addressed expeditiously, utilizing existing resources to resolve the issue. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. A written response to the complainant is not required; The "Issues, Steps to Investigate, Findings and/or Results" should be entered into the Event Reporting System (ERS); The manager will review complaints in the ERS.

Review of the facilities Complaint/Grievance Reports and Event Reporting System from 07/01/24 to the date of this survey failed to provide evidence of a reporting or investigation of the event on 07/31/24 identified by the Complainant. On 09/11/24 at 2:50, the Quality Manager confirmed no event report or complaint was identifed for the patient involved in the BERT event of 07/31/24.

Failure of the facility staff to address concerns voiced by the patient's spouse of possible assault utilizing existing resources, prevented timely investigation and resolution of a grievance regarding Patient #11.