Bringing transparency to federal inspections
Tag No.: A0118
Based on record review and interview, the facility failed to ensure that patient grievances were fully investigated in 1 of 3 patients (ID#5).
Findings include:
Record review of facility policy titled "Patient Rights and responsibilities" dated 06/2020 showed the following information:
Procedure:
The patient rights notification at a minimum will address the following patient rights as well as all additional federal, state, or local requirements. These statements include but are not limited to:
Payment and Administration
-To be informed and writing about the facility policies and procedures for initiation, review and resolution of patient complaints, including the address and telephone number of where complaints may be filed.
Record review of facility policy titled "Patient Grievance and Complaint Management Policy" dated 02/2021 showed the following information:
Purpose:
To establish a process for timely referral, prompt review, investigation and resolution of patient grievances and complaints.
2. Upon receipt of a grievance, the patient advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate, and resolve the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse and neglect). these grievances should be reviewed immediately given the seriousness of the allegations and the potential harm to the patient. Representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve any position delivery of care issues.
Record review of grievance resolution letter for patient (ID#5) dated September 8, 2023, showed the following information:
Our investigation consisted of the concerns your spouse expressed to us, which we understood to be regarding the quality of service and care you received during your visit. Your spouse shared concerns about surgical services, physician services, medication concerns, treatment concerns, emergency department cleanliness, and nursing services ...
Your concerns about physician services and surgery services are being addressed through the quality assurance program. This process is confidential, and I will not be able to provide any feedback as it is not available to you or to me. Please be assured your concerns have been fully reviewed.
Interview with patient safety staff (ID # 52) on 10/3/23 at 2:05 PM stated that grievances that involve physician care concerns are sent to PPEC (Physician Performance Evaluation Committee).
Interview with Peer Review Coordinator (ID#63) on 10/3/23 at 2:45 PM stated that issues regarding physician services are routed to PPEC. She stated that grievance for patient (ID# 5) was not routed to or reviewed by her and/or PPEC. Interview with patient safety staff (ID#52) confirmed at this time that the grievance was not routed to PPEC as it should have been.