HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to follow its policy and procedure to ensure that patient complaints or grievances were documented and processed in a timely fashion in 1 of 21 (Patient #1) charts reviewed.

The findings were:

The facility document titled, "Patient Rights and Responsibilities," last revised 1/2022, states, "Complaints, Concerns, and Questions. You and your family or guardian have the right to: tell hospital staff about your concerns or complaints regarding care. This will not impact your future care; seek review of quality of care concerns, coverage decisions, and concerns about your discharge."

The facility document titled, "3. Complaints/ Grievances for Patients, Family and/or Visitors and Service Recovery," last revised 1/19/2023, states, "Guidelines: 4. If the person hearing the complaint is unable to respond to or resolve the issue to the complainant's apparent satisfaction, (s)he should request assistance from the supervisor and/or manager of the relevant department. 5. Grievances should be reported to the Risk Management/Guest Relations/Quality department via the electronic reporting system, and trended for referrals to appropriate manager(s), department(s) or committee(s)."

The surveyor reviewed the Patient #1's medical record from 1/14/24 and it was noted:
ED Triage Note on 1/14/24 at 1635: "Immediately after [physician, Staff #12] left pt's [patient's] room, family member came out demanding to speak to a supervisor because the pt cannot be sent home with 'a migraine she's had for three days.' Charge called house sup [supervisor]. Pt and family given number to call to file a formal complaint."

The surveyor reviewed the facility grievance log from December 2023 to February 2024. The surveyor could not find any grievance documented for Patient #1.

The surveyor interviewed the Director of Quality Services (Staff #1) on 2/27/24 at 1108 at the facility. The surveyor asked if a grievance report was generated regarding this patient. Staff #1 replied, "No, we checked there is not one." The surveyor asked if a patient complains about their treatment, should the facility staff enter the complaint in the facility's electronic reporting system. Staff #1 stated, "Yes, and it wasn't done."

The surveyor interviewed the Nursing Supervisor (Staff #16) that interacted with Patient #1 on 1/14/24 by email. The surveyor asked what Staff #16 remember about their interaction with Patient #1 and the patient's family. Staff #16 replied, "I recall be [sic] contacted my [sic] CN [charge nurse] and speaking with the PT[patient]/family member. The PT minimally participated in the conversation. The family member did not appear to be happy with anything that staff was attempting to do for the PT. PT's family member later called the HS office to make a complaint. I did my best to express my apologies and gave them the name and phone number to Patient Relations and informed them that they would be able to further assist them on Monday with any formal complaint they wished to pursue."