HospitalInspections.org

Based on interviews, hospital document review and the course of a complaint investigation, it was determined the staff failed to follow the grievance process as determined by the facility's policy.

The findings include:

Review of supplemental information provided by the complainant evidenced the complainant had called the ED speaking with a "nurse named (name)" and requesting a formal meeting to discuss concerns related to the care received while in the ED on 8/26/21. The complainant stated the ED Director never got in touch to arrange a meeting or address their concerns. The surveyor found the "nurse" the complainant spoke with, who was the Administrative Assistant (Staff #17) to the Director of the ED. During an interview on 12/8/21 Staff #17 remembered taking the call while the ED Director was on vacation and stated the information was shared with the Director of ED via email. Staff #5, the ED Director was able to provide the surveyor with a copy of the email. Staff #5 confirmed during an interview they made an attempt to contact the complainant by phone but ware unable to reach the complainant. Staff #5 stated there were no additional attempts made to contact the complainant and confirmed the grievance was not forwarded to the Patient Safety Coordinator for documentation, investigation and resolution.

The facility policy titled "Patient Grievance and Complaint Management Policy revised 6/2018" was reviewed on 12/8/21 and contained the following information in part: "A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative. A written complaint also includes those complaints received via electronic mail or facsimile. Regardless of the form in which a complaint is received, whenever a patient or patient's representative requests a response from the facility, the issue is defined as a grievance... Upon receipt of a grievance the Patient Safety Coordinator shall be notified and shall confer with the appropriate Department Director to review investigate and resolve with the patient and/or the patient representative within seven days of the receipt of the grievance... In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion... The written notice must be communicated appropriately to the patient or the patient's representative in a language and manner the patient or the patient's representative understands. When a patient communicates a grievance via email, the response may be provided via email. However, the response must contain the aforementioned elements."

The failure of hospital staff to execute the grievance process as outlined in the facility policy was discussed with Staff #1 and Staff #2 at the time of discovery and with the management team prior to exit on 12/9/21.