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Based on interview and document review, the hospital failed to ensure that patient grievances were promptly addressed, for 1 of 11 patients reviewed (P1), who reported to an Intensive Care Unit (ICU) nurse that she was verbally and physically abused by a hospital employee who worked in the ICU. Findings include:

P1's hospital discharge summary, dated 03/31/14, indicated that P1 was admitted to the ICU on 03/26/14, transferred to a neurological unit on 03/29/14, and discharged to home on 03/31/14, with home care services and therapy services arranged. A Patient Complaint form, dated 03/31/14, indicated that P1 reported to patient representative (PR)/(D) that she was physically and verbally abused by Nurse (F)/RN on 03/29/14, just prior to being transferred out of the ICU. P1 alleged that the incident was witnessed by Nurse(G)/RN who was also at P1's bedside when the incident occurred.
P1 was interviewed on 06/10/14 at 9:15 a.m. P1 stated that she was abused by Nurse (F)/RN on her last day in the ICU, which was 03/29/14. The incident occurred at P1's bedside when two nurses were getting her ready to transfer to another hospital inpatient unit. P1 stated she talked to Nurse (G) about it when Nurse (G) transported P1 to the inpatient unit. After P1 got transferred into bed on the inpatient unit on 03/29/14 and Nurse (G) left, P1 stated that she immediately reported the incident of abuse to the hospital's Patient Advocate.

Nurse (G)/RN was interviewed on 06/26/14 at 2:40 p.m. Nurse (G) stated that she was at P1's bedside the entire time P1 was readied for transfer to the inpatient unit. Nurse (F)/RN and Nurse (H)/RN were also present and assisted with P1's discharge process from the ICU, which was hurried because P1's bed was urgently need for another critical patient. Nurse (G) observed that Nurse (F)'s tone of voice was directive, somewhat impatient, and rather loud. Nurse (F) physically cued P1 not to get out of bed by placing his hand on P1's chest/shoulder area. Nurse (F) did not push P1. Nurse (G) did not observe Nurse (F) slap any items from P1's hands. With the exception of Nurse (F)'s tone of voice, Nurse (F)'s actions with P1 were professional and appropriate. While Nurse (G) transported P1 to the hospital inpatient unit, P1 talked continuously about Nurse (F)'s abusive behavior toward her. Although Nurse (G) was aware of P1's perception that she was abused by Nurse (F), Nurse (G) did not communicate this information to anyone, despite Nurse (G)'s personal observations of Nurse (F)'s improper tone of voice toward P1. Patient Representative (PR)/(D) was interviewed on 06/26/14 at 10:05 a.m. PR/(D) stated that P1 called PR/(D) on 03/31/14 at 11:15 a.m. to file a grievance about how she was mistreated by Nurse (F)/RN on 03/29/14. PR/(D) went to P1's inpatient room on 03/31/14 to meet with P1 in person about the matter. On 03/31/14 after PR/(D) met with P1, PR/(D) reported P1's allegation of being mistreated by Nurse (F) to Managers (B) and (E).

Manager (E)/RN was interviewed on 06/26/14 at 9:15 a.m. Manager (E) stated PR/(D) notified her on 03/31/14 that P1 had just reported that she was mistreated two days earlier by a hospital employee in the ICU. Manager (E) conducted an immediate investigation on 03/31/14. Manager (E) re-educated Nurse (F) regarding acceptable ways to interact with patients. No educational follow-up was provided to Nurse (G) regarding Nurse (G)'s failure to recognize P1's verbal complaint of abuse as a patient grievance that warranted referral to hospital leadership on 03/29/14, for prompt follow-up of P1's allegation.

The hospital's Patient Grievance Policy, approved March 2014, defined a complaint as "a verbal expression of dissatisfaction by a patient (or anyone on behalf of a patient) to the hospital concerning the quality of care or service provided by the hospital." The policy defined a grievance as a complaint that is made to the hospital by a patient (or anyone on behalf of the patient) that is not resolved promptly by staff present on the patient's unit or department." The policy indicated that "any complaint (whether written or oral) alleging abuse, neglect, patient harm, or non-compliance with Medicare Conditions of Participation is a grievance...the grievance committee (acting through the Patient Representative) must review the grievance, investigate it, attempt to resolve it, and report the resolution to the patient in writing as soon as possible, but no later than seven days after the patient informed staff of the grievance." The policy did not provide any direction to unit staff about their roles regarding unresolved patient grievances or the need to promptly refer grievances alleging patient abuse to leadership staff.

A letter from PR/(D) to P1, dated 03/31/14, indicated that the hospital had initiated an investigation in response to P1's complaint about being mistreated by an ICU employee. A second letter from PR/(D) to P1, dated 04/10/14, indicated that the hospital had reviewed P1's concern and the matter had been concluded.