HospitalInspections.org

Based on record review and interview the facility failed to follow the process outlined in the complaint/grievance policy to acknowledge and investigate 1 complaint/grievance in a total of 3 complaints/grievances reviewed.

Findings Include:

A review of the facility's policy titled, "Responding to Patient/Family Complaints and Grievances," effective 1/31/21 revealed, " ...Staff members should make every effort to promptly address patient complaints ... A staff member who receives a grievance about patient care or service is required to inform their manager of the grievance ... The Patient Relations Department will notify patients of their rights, inform them of the grievance process, and set up a timeline of up to 45 days for completion of the grievance process ..."

A review of the facility's policy titled, "Patient Rights and Responsibilities," effective 7/10/24 revealed, " ...Patients, their guardians or family members who feel that their concerns have not been adequately addressed should contact the Department of Patient Relations ... Inquires will be reviewed in a timely manner and resolved whenever possible ..."

A review of the "Patient Relations voicemail log" revealed a voicemail from Complainant A on 5/30/25 at 11:00 AM which revealed, "Calling regarding the care my mother [Patient #1] received. Would like her care reviewed that resulted in her death. Would like to make sure this also does not happen to anyone else." There was no additional documentation including acknowledgment, investigation, follow-up or resolution as of 6/10/25 (date of survey).

An interview was conducted on 6/10/25 at 2:35 PM with Patient Relations (PR) Director E. When asked what the expected initial response time was for initial contact made after grievances were made, PR Director E stated that the expectation is that contact is made within 1 to 2 business days.