HospitalInspections.org

Based on review of facility policy, review of facility grievance/complaint logs, medical record review, and interviews, the facility failed to ensure a patient grievance was resolved related to a complaint for one 1 patient (#1) of 5 patient's reviewed.

The findings included:

Review of facility policy, "Patient/Guest Complaint and/or Grievance Management" last reviewed 6/24/2022, showed "...[B] grievance: a formal or informal written or verbal complaint that is made to the facility, or the patient's representative, regarding the patient's care [when the complaint is not resolved at the time of the complaint by staff present], abuse or neglect, issues related to the hospital's compliance with the Centers for Medicare and Medicaid Services [CMS] Hospital Conditions or Participation [COP]...[5] patient complaints that become grievances also include situations where a patient or patient's representative telephones the hospital with a complaint regarding patient care...[4] the director/manager or their designee will initiate the review and investigation of the grievance...will log findings, actions, and/or other interventions to grievance resolutions to the on-line Patient/Guest Feedback System...[5] after receipt of grievance, on average, grievances are resolved within seven days of the receipt of the grievance for the provision of a response to the grievance will be made..."

Review of the grievance/complaint logs showed the patient was not listed on the logs.

Medical record review showed Patient #1 was admitted to the facility on 9/19/2022 related to an elevated blood pressure and stroke like symptoms. He was diagnosed with an Hypertensive Emergency where he was treated and discharged home on 9/21/2022.

Medical record review of a Case Management (CM) note dated 9/21/2022 at 4:12 PM showed "...CM received a message from pt.'s [patient's] wife [related to] lack of care from the staff. Information was taken and call placed to the HR [human resources] and [Chief Nursing Officer-CNO] several times. Finally, information was given to the house supervisor..."

During an interview on 9/28/2022 at 12:15 PM, the Chief Nursing Officer (CNO) stated the patient's wife had called the Case Manager on 9/21/2022 and reported concerns related to the dayshift nurse on 9/20/2022 had not provided care to her husband. The Case Manager took the complaint and attempted to call Human Resources and the CNO related to the complaint. The Case Manager had reported the complaint to the house supervisor for follow-up. The house supervisor spoke with the ED [Emergency Department] nurse. He then left the complaint for the ED Nurse Manger to follow-up and the complaint was not followed-up by the facility after that. The CNO confirmed the complaint should have been converted to a grievance and follow-up did not occur.

During an interview on 9/28/2022 at 12:25 PM, the Emergency Department Nurse Manager confirmed there was no follow-up related to the grievance. She stated "...it just got stalled up in the system and should have been entered as a complaint and followed up on..."

During an interview on 9/28/2022 at 12:30 PM, Case Manager #1 stated she had received a call from the patient's wife on 9/21/2022 who was very angry about the care the patient had received in the ED on 9/20/2022. She stated "...I tried to call HR and the CNO but could not reach them. I called the house supervisor and told him about the complaint..."