HospitalInspections.org

Based on record review and interview the facility failed to ensure patient complaints/grievances are thoroughly investigated and addressed in a timely manner in 1 of 4 patient (Pt #6) complaints/grievances reviewed in a total sample of 4 records reviewed.

Findings:

A review of the facility policy #CPM.0020, titled "Patient Complaint Reporting and Investigation", last reviewed 4/6/2022, revealed: "Policy: [Facility name] is committed to actively seeking, listening and responding to the needs, preferences, concerns and grievances of our patients and their families...Procedure: A. Each patient is provided information on how to voice a complaint via the 'Patient Admission' folders...D. Handling of complaints received after patient is discharged or left from the hospital or clinic....3. Process/workflow for investigation of complaints: i. Patient Relations receives a phone call that a patient or patient's representative (aka (also known as) complainant) would like to file a complaint. ii. Patient Relations Coordinator (PRC) makes contact with the complainant (in some cases this is not the patient), and discusses his/her concerns During this initial call PRCs screen the concerns to determine if it is a complaint or grievance."

A review of the facility admission booklet titled, "Your Stay at [facility name]", dated 10/2021, revealed: "Patient Rights and Responsibilities: 19. If you have any concerns or complaints about your care, treatment, services or any patient safety issues, please let us know so that we can address them. You are encouraged to contact the department manager. You may also contact our Patient Relations Department at [phone number]."

A review of the Patient Relations call log on 6/21/2022, revealed: "Complainant A for Patient #6 called with the following concern: Complaint about Dr. [name] and past surgery experience as the patient has an upcoming surgery. Caller is concerned that after a major surgery he was sent home on the same day and complains that he's having surgery again because it wasn't done right the 1st 2 times."

During an interview on 9/6/2022 at 3:15 PM, Patient Relations (PR) Manager D stated, "The PR department received a call from Complainant A on 6/21/2022. We initially thought this complaint was going to be triaged to MCW (Medical College of Wisconsin) but then we noted the patient was readmitted. The plan was for PR coordinator to follow up with Patient #6 and mother during that admission, unfortunately it did not occur. We did not follow up with the patient as we should have."