HospitalInspections.org

Based on interview and document review the facility failed to log complaints received related to patient care and failed to follow facility policy in one of one patient (pt. #1) complaints resulting in the potential to fail to track patient complaints and failure to answer patient complaints. Findings include:

On 11/3/2021 at 1130 an interview occurred with staff D, the patient experience representative of the facility. During the interview staff D was queried if she had any interaction with patient #1's family concerning a complaint. Staff D stated the patient's family had made a complaint to patient experience regarding the patient's care. Staff D further stated that the family was satisfied with the facility's response to their complaint and that she had considered the complaint resolved.

On 11/3/2021 at 1140 staff D was asked if a complaint log could be provided. Staff D responded, "(we) actually do not keep a complaint log...if a complaint is resolved at the time it is received then it is considered complete with no further need for follow-up as a grievance would require. Staff D was then asked if she could produce any notes or communication concerning the complaint. Staff D stated, "no...we do not keep any notes for complaints."

On 11/3/2021 at 1145 a request was made for the facility's complaint and grievance policy. On 11/3/2021 at 1150 a document review occurred of the policy titled, "Patient Complaint / Grievance," dated 09/2021. According to the policy under the subtitle "Grievance" on page 1, the policy stated the following, A grievance is considered to be any or all of the following. For purposes of staff education, these may be referred to as "red alert" issues:

1. Any complaint received during or after a patient encounter regarding the following is considered as a grievance. These include issues relating to: a) the patient's medical care, b) the patient's providers (physicians, nurses, other providers)..."