HospitalInspections.org

Based on interview and record review, the facility failed to follow their process for prompt resolution of patient grievances for 1 (P-1) of ten patients sampled for patient rights, resulting in the potential for poor outcomes for all patients, utilizing the grievance process.

Review of the medical record for P-1 revealed a progress note authored by Staff L on 12/03/23 at 1720, stating, "Patient's nurse (Staff L) came to charge and stated patient was making a complaint about being punched. House supervisor called and updated. This nurse went in to talk with the patient and make a report. Patient wrote on her white board that it was last night or the night before. She wrote it was a black fellow. She said she was punched in the stomach. Patient gown was pulled up and patient pointed to the area near her naval. No bruising or redness noticed. Patient's nurse shown notes."

Review of facility's event reporting system document titled "Current Summary", dated 12/04/23 demonstrated that the facility documented the incident as 'Harm/Abuse/Neglect.' Further review also revealed under 'Outcome Notes', dated 12/04/23 (no time stamp, no author) states "This issue was addressed by the Clinical House Supervisor at the time of the complaint. No further information was provided to our office. Clinical House Supervisor did not send any needed follow-up by our office. We did not receive a call from the husband. Issue addressed at time of incident ."

Review of facility complaint and grievance log revealed no entries under grievances regarding abuse allegations for P-1.

An interview was conducted with patient advocate Staff P on 01/31/24 at approximately 1100. Staff P was queried if P-1's allegation met the facilities definition of abuse. Staff P replied, "yes." Staff P was next questioned why P-1's 'allegation of abuse' was not a 'grievance'. Staff P explained that "it was not escalated to her." Staff P explained that in the past, she would receive an email from the house supervisor, who had investigated the complaint. Staff P stated that she did not receive an email from the house supervisor, which meant that the investigation ended with the house supervisor 'not escalating it.'

Review of policy "Patient Complaint Grievance Process," (no policy #) reviewed 08/31/21, states under 'definitions', paragraph #5, "A complaint is considered a grievance when it falls within one of the following criteria: (A.) verbal patient care complaint that is not resolved at the time of complaint by staff present, is postponed for later resolution, requires investigation and or further actions for resolution. (B.) The complaint is in writing. This includes faxes, e-mails, and comments on patient surveys when the patient requests resolution. (C.) Any written or verbal complaint regarding abuse or neglect, patient harm or hospital compliance with Center for Medicare and Medicaid (CMS) requirements."

Review of policy titled, "Alleged Abuse or Neglect of Patients by a Colleague, Volunteer, Physician or any Agent of the Hospital," (no policy # or date) stated under 'procedure D,' "The Patient Advocate/ Care Experience Specialist or Risk Management will coordinate the investigation. E. The steps involved in handling an investigation may include but are not limited to: a. Review the complaint/allegation. B. Review the medical record. C. Interviews with key individuals involved in the complaint/allegation. D. Communication with the appropriate leadership."

On 01/31/23, an interview was conducted with Director of Quality Staff A. Staff A stated that the facility was actively looking for a form to document house supervisor complaint investigations. Staff A stated that an email may not be the ideal way to document patient/staff interactions.