HospitalInspections.org

Based on record review and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify complaints as grievances, and to conduct a thorough investigation in accordance with hospital hospital policy for 3 of 3 (R5, R6, R7) patient complaints/grievances reviewed.
Findings:

Review of the Hospital Policy titled, "Patient Complaint, Grievance and Service Recovery Policy", provided by S6Quality as current, revealed the following, in part:
Definition of Terms: "Complaint: Is a concern represented by a patient or patient's representative that can be addressed and/or resolved in a timely manner by staff members who are present at the time of the complaint...Verbal complaints received after discharge regarding patient care should be forwarded to the Risk Management Department."
Patient Grievance: "Is a written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care, abuse or neglect.... This includes when the verbal complaint about patient care is not addressed and/or resolved to the satisfaction of the patient or patient's representative while the patient is still receiving care at the facility." ...All grievances should be forwarded immediately to the Patient Representative/Risk Manager Department. 2. Upon receipt of a grievance, the Risk Management Department will handle and direct the grievance follow up process and shall confer with the appropriate department leadership to review, investigate and resolve with the patient and/or the patient's representative within seven days of receipt of the grievance...4. Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systematic problems indicated by the grievance. 5. 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 at the date of completion....7...However, in all cases a written notice of response with the aforementioned elements must be provided to each patient's grievance..."


Patient #R5
Review of a grievance stamped as received 1/19/18 revealed a patient's wife had written a letter of complaints and suggestions related to his care and the hospital.. Review of the complaint documents revealed a letter from a former patient's wife (patient was admitted during December for surgery) with complaints that included his surgical bandages had not changed when the physician noted they needed to be changed, and reported having to ask staff 6 or 7 times before they were changed, on another shift. The patient representative also reported that the patient struggled for 3 days and nights post discharge because they (the patient and his wife) had not been educated on the physical challenges and needs of the patient when he was discharged to his home setting. In her letter she also reported a ladies restroom (public) with a toilet that sprayed water so hard upon flushing that the water hit her in the face, making it necessary to wash her face and glasses. Further review of a print-out, from the Complaint software used by the hospital, related to this grievance revealed following information: Date Event Occurred: 12/7/2017, "Was this a complaint, a compliment, or an assist? : "Complaint", Date event reported: 1/22/18, Status: "resolved", Substantiation: blank, Activity Date/Date Assigned: 1/26/18, Date Resolved: "1/26/18", Resolution type" Investigated and Closed. A Description was documented as, "Patient's wife wrote letter with several suggestions/complaints for Nursing...-also plumbing problem for first floor Women's restroom. CNO followed up with wife." Further review revealed no documentation of an investigation, results of an investigation, or written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or his representative.


Patient #R6
Review of a document titled Activity Detail With Items related to Patient #R6 revealed a grievance related to a Breach of Confidentiality. Further review Patient #R6's wife reported while her husband was admitted in May, 4 days prior to her submission of this grievance) someone in ICU provided information regarding her husband to a unauthorized family member, who was employed by the hospital. The subject was labeled as a "Complaint Breach of Confidentiality. The document revealed the grievance was received 5/21/18 by telephone, and completed 5/22/18. Further review revealed no documentation that written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or his representative.


Patient #R7
Review of a document titled Activity Detail With Items related to Patient #R7 revealed a grievance documented as a "Care complaint" of a patient's son regarding his mother's colostomy bag leaking throughout the previous weekend and was being told the hospital did not have one to replace it. Further review revealed no information of when the grievance was made, to whom, or in what form. The only details on the documentation was a follow-up summary by a nursing manager. Further review revealed no documentation that written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or her representative.


In an interview 6/11/18 at 1:30 p.m. with S6Quality and S12PtAdv both reported that they were under the impression that a written notification did not have to be sent if a grievance was received after a patient had been discharged from the hospital. After a review of the hospital's policy and procedure for grievances, both S6Quality and S12PtAdv agreed that the hospital had been treating grievances as complaints according to the hospital policy definition of a complaint and of a grievance. S6Quality also verified that the policy, stating that all grievances would require a written notification that included 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, was not being followed. S12PtAdv verified the above noted grievances had been considered complaints, and the documentation provided was all inclusive.

Based on record reviews and interview, the hospital failed to ensure it implemented its grievance policy related to the written notice of its decision in its resolution of the grievance as evidenced by failure to have the resolution letter to include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 3(#1, R1) of 3 (R5, R6, R7) grievances reviewed, from complaints/grievances received January 2018 through May 2018.
Findings:


Review of the Hospital Policy titled, "Patient Complaint, Grievance and Service Recovery Policy", original date 4/09/06, provided as current revealed the following, in part:
Definition of Terms: "Complaint: Is a concern represented by a patient or patient's representative that can be addressed and/or resolved in a timely manner by staff members who are present at the time of the complaint...Verbal complaints received after discharge regarding patient care should be forwarded to the Risk Management Department."
Patient Grievance: "Is a written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care, abuse or neglect.... This includes when the verbal complaint about patient care is not addressed and/or resolved to the satisfaction of the patient or patient's representative while the patient is still receiving care at the facility." 5. 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 at the date of completion....7...However, in all cases a written notice of response with the aforementioned elements must be provided to each patient's grievance..."


Patient #R5
Review of a grievance stamped received 1/19/18 revealed a patient's wife had written a letter of complaints and suggestions related to her husbands admission in December 2017. Review of the complaint documents revealed a letter from a patient's wife with complaints that included his surgical bandages not changed when the physician noted they needed to be changed, and reported having to ask staff 6 or 7 times before they were changed, on another shift. The patient representative also reported that the patient struggled for 3 days and nights post discharge because they had not been educated on the physical challenges and needs of the patient in his home setting. In her letter she also reported a ladies restroom (public) with a toilet that sprayed water so hard upon flushing that the water hit her in the face, making it necessary to wash her face and glasses. Further review of a print-out, from the Complaint software used by the hospital, related to this grievance included the following information: Date Event Occurred: 12/7/2017, "Was this a complaint, a compliment, or an assist? : "Complaint", Date event reported: 1/22/18, Status: "resolved", Substantiation: blank, Activity Date/Date Assigned: 1/26/18, Date Resolved: "1/26/18", Resolution type" Investigated and Closed. A Description was documented as, "Patient's wife wrote letter with several suggestions/complaints for Nursing...-also plumbing problem for first floor Women's restroom. CNO followed up with wife." Further review revealed no documentation of an investigation, results of an investigation, or written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or his representative.


Patient #R6
Review of a document titled Activity Detail With Items related to Patient #R6 revealed a grievance related to a Breach of Confidentiality. Further review Patient #R6's wife reported while her husband was admitted in May, 4 days prior to her submission of this grievance) someone in ICU provided information regarding her husband to a unauthorized family member, who was employed by the hospital. The subject was labeled as a "Complaint Breach of Confidentiality. The document revealed the grievance was received 5/21/18 by telephone, and completed 5/22/18. Further review revealed no documentation that written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or his representative.


Patient #R7
Review of a document titled Activity Detail With Items related to Patient #R7 revealed a grievance documented as a "Care complaint" of a patient's child regarding their mother's colostomy bag leaking through the previous weekend and was being told the hospital did not have one to replace it. Further review revealed no information of when the grievance was made, to whom, or in what method. The only details on the documentation is a follow-up summary by a nursing manager. Further review revealed no documentation that written notification of the steps taken to investigate, the results of the investigation, or the hospital contact information was provided to the patient or her representative.


In an interview 6/11/18 at 1:30 p.m. with S6Quality and S12PtAdv both reported that they were under the impression that a written notification did not have to be sent if a grievance was received after a patient had been discharged from the hospital. After a review of the hospital's policy and procedure for grievances, both S6Quality and S12PtAdv agreed that the hospital had been treating grievances as complaints according to the hospital policy definition of a complaint and not as a grievance. S12PtAdv reported no written notification had been sent on the grievances for S5, S6, or S7. S6Quality also verified that the policy, defining complaints and grievances, and stating that all grievances would require a written notification that included 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, was not being followed.