HospitalInspections.org

Based on policy and procedure review, medical record review, complaint/grievance log review, and staff interviews, the facility staff failed to identify a patient complaint as a grievance in 1 of 2 sampled patients (Patient #16).

The findings include:
Review of a policy titled "Patient Grievance/Complaint Management" with revision date of 02/2021, revealed "...Grievances: Complaints meeting any of the following criteria are considered a grievance and require a written response. 1. A written or verbal complaint that cannot be resolved at the time of the complaint by staff present and requires further investigation and/or related actions for resolution. 2. Complaints regarding the patient's care or with the allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more CoPs (Conditions of Participation)...a. Grievances involving situations that potentially endanger the patient such as harm or neglect should be reviewed immediately...."

Review of a closed medical record of Patient #16 revealed a 51 year old female presented to the Emergency room on 04/24/2023 for worsening redness on right leg after hitting the bumper on her truck. Review of a report titled "Patient Feedback" dated 04/26/2023 revealed "....(Patient #16) says no one is helping her get up to go to the bathroom because she cannot walk. She says she fell at the bedside trying to open the door..."

Review of the complaint log revealed Patient #16 listed as a complaint. Review of the grievance log revealed Patient #16 did not have an entry on the grievance log.

Interview on 05/17/2023 at 1430 with DQM #1 revealed the complaint should have been treated as a grievance based on the need for background work. Interview revealed the grievance policy was not followed.

NC00194042