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Based on record review and interview the facility failed to establish a process for the prompt resolution of patient grievances and failed to contact the patient who filed the grievance with resolution, in one of 5 grievances reviewed (Patient #1 of #2, #3, #4, and #5).


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On 10/11/2018 in the library an interview with the housekeeper staff #6, who was identified by the work schedule as the housekeeper the patient had observed cleaning his room and complained about, was interviewed. She gave a step by step, verbal process for cleaning a patient's room, that included changing the cloth used to wipe soiled or potentially contaminated surfaces 5 times and changing the mop heads between patient room and bath room floors.

The complainant, patient #1, had reported he observed housekeeper #6 cleaning his room and "she never changed the cloth she was using". Pt #1 indicated she wipe the trash can lid, his bed side table and then the bathroom and never changed her cloth. He also reported she never changed the mop and mopped the floor of his room and the bathroom floor with the same mop head.

With the assistance of the manager for the housekeeping department, a record of pt #1's verbal complaint to the patient ambassador (staff who round and interview patients for complaints and satisfaction reports) was located and presented for review.

Review of the document revealed only the verbal complaint as described above. The documentation did not included an investigation or resolution to the noted complaint.

An interview with the patient ambassador, staff #7, who took pt #1's complaint revealed she always resolved the patient compliant, unless it occurred near the end of her shift then she would pass it on to the on-coming patient ambassador for resolution. The housekeeping manager confirmed there were no other entries concerning patient #1's compliant and therefor there was no documentation the compliant had been investigated, or resolved. There was no documentation the patient had been re-interviewed or provided any feed back on their compliant.