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Based on record review and interview the facility failed to send a written response of grievance decision or resolution to a patient's (P#1) representative (FM#1) and patient (P#2) of five patients reviewed for patient rights.
The findings were:
P#1
Review of medical records revealed P#1 was an 86 year old female who was admitted to the facility on 08/07/14 and treated for incarcerated right inguinal hernia with distal small-bowel obstruction. P#1 's condition deteriorated. P#1 suffered a cardiac arrest with anoxic encephalopathy (absence of oxygen to the brain) and expired at the facility on 08/17/14.
An interview with FM#1 on 01/30/15 at 9:10 a.m. revealed FM#1 complained to facility staff and Staff #3 regarding concerns with P#1's quality of care, nursing services, patient rights and P#1's death. FM#1 stated the facility did not resolve his grievances in a timely or reasonable manner. FM#1 also indicated he did not receive any written response of grievance decision or resolution by the facility.
Interview with Staff #3 on 01/30/15 at approximately 1:30 p.m. indicated FM#1 voiced complaints about P#1's quality of care and P#1's death. Staff #3 confirmed no written response of grievance decision or resolution was sent to FM#1. No record of the complaint and resolution/response to the family was provided to this Surveyor.
Review of the facility's Patient Complaints/Grievances policy effective date 10/31/14 indicated the facility was required to send a written notice of decision for each issue defined as a grievance. The policy also indicated all patient complaints to be incorporated into the Complaint/Grievance data set. No record of FM#1's complaint/grievance was documented on the facility's Complaint/Grievance data set.
P#2
Review of medical records revealed P#2 fell at the facility on 05/19/14 while visiting a family member and sustained a right shoulder anterior dislocation. Facility records dated 05/19/14 indicated P#2 received a Right Shoulder Closed Reduction and alignment at the facility. P#2 revisited the facility's Emergency Department on 05/26/14 and 06/06/14 with complaints of increased right shoulder pain.
Interview with P#2 on 01/30/15 at 08:30 a.m. revealed P#2 complained to the facility on 05/19/14, 05/26/14 and 06/06/14 regarding concerns with the facility's quality of care, nursing services, physician services and lack of administration follow-up to her complaints. P#2 indicated she had severe pain from the fall and did not receive a written notice of grievance decision or resolution.
Interview with Staff #3 on 01/03/14 at approximately 1:45 p.m. confirmed P#2 and the patient's family member (FM#2) voiced complains about P#2's fall at the facility and subsequent medical treatment at the facility. Staff #3 indicated no written response of grievance decision or resolution was sent to P#2 or FM#2 according to facility policy and regulation. Staff #3 said the facility's Complaint/Grievance data set had inaccurate data that documented a date of resolution and response letter was sent to P#2 or FM#2
Review of the facility's Complaint/Grievance data set dated 06/06/14 confirmed P#2's and FM#2's complaint regarding the facility's quality of care. No documents were provided to this Surveyor that the facility sent a written notice of complaint/grievance decision or resolution to P#2 and or FM#2.
During the exit conference on 01/30/15 at the facility's conference room, the facility was given an opportunity to ask questions, provide additional information and documents related to the deficient practice identified during the complaint survey. No additional information was given.