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Based on record review and interview, the hospital failed to ensure an effective grievance process was in place. This deficient practice is evidenced by: 1) the facility failing to thoroughly identify, investigate and follow the grievance process for 1 patient (Patient #3); and, 2) the facility failing to ensure a patient complaint requiring further investigation was recognized as a grievance for 1 (Patient #2) of 2 (#2, #3) patients reviewed for complaints/grievances in a total patient sample of 3.
Findings:

Review of the hospital's grievance policy and procedure hospital policy titled Patient Complaints and Grievances Chapter: Rights and Responsibility Last Revised: 02/21/2023 revealed in part that all verbal or written complaints regarding abuse, neglect, or hospital compliance with CMS requirements are considered grievances. A written complaint is always considered a grievance. As soon as possible, but no later than within two business days of receipt of the grievance, the patient advocate will contact the grievant to obtain additional details of the complaint. The grievance investigation steps and results will be documented on the grievance in the Complaint and Grievance Management System.

Further review of the hospital policy revealed a patient grievance is defined as a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or patient's representative, regarding patient's quality of care, abuse or neglect, issues related to the hospital's compliance with the CMS CoP's or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations.

Patient #3
1) Review of Patient #3's nurses notes dated 12/29/2023 at 1:45 p.m. revealed that the family called the patient's nurse to the room because they found an old bloody gauze on the patient's left wrist that appeared to be from a previous venous lab draw. The patient was diagnosed with a deep vein thrombosis in the left arm and was not supposed to have needle sticks in the left arm. The family requested to speak to the supervisor and the CEO.

On 02/29/2024 at 11:10 a.m., interview with Patient' #3's nurse, S2RN, revealed that she was aware that Patient #3's family had complained about an old bloody gauze that was found on the patient's left wrist. When asked if this had been investigated to determine what had happened, S2RN stated she was not sure but thought the phlebotomist had stuck the patient in the left arm.

Review of the grievance log, presented as current, by S1Director of Quality, revealed no grievance related to Patient #3.

Interview with S1Director of Quality on 02/29/2024 at 11:45 a.m. revealed that she was unaware of the complaint made by Patient #3's family on 12/29/2023 regarding the needle stick in the left arm. S1Director of Quality further stated that Patient #3's family had met with S3CEO last week about several complaints. When asked if these issues had been identified and thoroughly investigated as grievances and followed the hospital's grievance process, S1Director of Quality stated no.

Interview with S3CEO on 02/29/2024 at 2:30 p.m. revealed that Patient #3's family had made multiple complaints about the patient's care and he had talked to them multiple times. S3CEO provided the surveyor with an email (dated 02/10/2024) from Patient #3's family member sent to S3CEO complaining about a nurse's "temperament" and "demeanor" when talking to the family member on the phone. The email further stated that the nurse failed to update the family member on the patient's labs or medical status when they called.
When asked if these above complaints had been identified as grievances, been thoroughly investigated, and followed the grievance process, S3CEO stated no. S3CEO further stated that looking back, these should have been identified as grievances and the grievance process should have been implemented.


Patient #2
2) A review of the complaint and grievance log revealed Patient #2 had an incident dated 11/05/2023, for which a complaint was received on 12/01/2023. The last documented communication from the hospital was 12/04/2023.
Patient #2"s daughter stated prior to their mother passing away S4RN called her sister and stated that she saw there was a signed DNR, and the sister said, "No, we revoked that." Complainant stated that S4RN went on to say "are you sure that is what you want? She may be a vegetable for the rest of her life." The daughter of the patient said S4RN was insistent and it was troubling for her sister. She stated S4RN even made the comment that it was "not a wise choice." She also stated that S4RN said they could not go visit Patient #2, and the visiting hours will start at 9:00 am. Patient #2's daughters felt S4RN was uncaring, dogmatic, and insistent on getting her way. On Friday, 12/01/2023 the hospital followed up with the ICU director, who stated she was not aware of the incident, but that S4RN had resigned. On Monday, 12/04/2023, the hospital followed up with the complainant for resolution.

In an interview on 02/29/2024 at 11:45 a.m., S1Director of Quality reviewed the complaint and grievance log and stated this incident was deemed a complaint and not a grievance; therefore, the family was not sent any letter. She also verified the incident was received on 12/01/2023 and the last communication for resolution with Patient #2's daughter was on 12/04/2023.