HospitalInspections.org

Based on record review and interview the facility failed to document a patient complaint as a grievance per facility policy and failed to provide a written or verbal response in 1 of 3 patient grievances (Patient #1) in a sample of 3 records reviewed.

Findings include:

A review of facility policy "Complaints and Grievances" Approval Date 5/7/2013 revealed, "...Definitions...Grievance: A formal written or verbal grievance that is filed by a patient or a patient's designated representative, when a patient issue cannot be resolved promptly by Fort Healthcare staff members caring for patients. A patient grievance may involve issues related to the patient's care when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, or to the hospital's compliance with CMS Hospital Conditions of Participation (CoP) or a Medicare beneficiary billing complaint. All verbal or written complaints regarding abuse, neglect, patient harm, or compliance with CMS requirements are considered grievances for the purposes of these requirements...Procedure...Grievance...Once in receipt of a grievance, the Manager/Director or Sr. Director/VP of the area involved initiates the investigation by: 1. Contacting the patient (or representative designated) within five (5) working days of receipt of the grievance to acknowledge the grievance and gather additional information from the complainant...6. A written response will be sent to the complainant within seven (7) days of receipt of the grievance by the department manager/director, or the Sr. Director/VP, as appropriate...After all steps to investigate the grievance have been resolved, the Fort HealthCare contact person will follow-up either in-person or via phone with the patient/representative to determine if the patient/representative is satisfied with the actions taken..."

A review of Patient #1's medical record revealed Patient #1 was admitted to facility Emergency Department (ED) on 5/11/2022 with complaints of vomiting for 24 hours. During the stay in the ED from 3:26 PM-7:47 PM, Patient #1 made a verbal complaint of abuse against EST L, a caregiver in the ED.

A review of facility ED "Grievance Resolution Log 1/1/2022-Present (7/5/2022)" revealed no documented grievance from Patient #1 regarding events of 5/11/2022.

A review of facility ED "Behavior, Complaints/Concerns & Miscellaneous Events" from 1/1/2022-6/30/2022 revealed Event #239161 which was entered into facility's "Healthcare Safetyzone" event reporting system by Director of Emergency Services D on 5/11/2022 at 8:12 PM, documenting Patient #1's complaint.

A review of Healthcare Safetyzone Event #239161 revealed interviews conducted by Director of Emergency Services D and Risk Manager N with Patient #1 on 5/11/2022 at "approximately 7:20 PM", ED Registered Nurse (RN) H on 5/11/2022 at 7:33 PM, and Emergency Services Technician (EST) L on 5/11/2022 at 9:45 PM. An interview via telephone with Patient #1 was conducted by Risk Manager N on 5/12/2022 at 9:11 AM. Interviews were conducted by Risk Manager N, Chief Nursing Officer K and Human Resources Manager I with EST L on 5/12/2022 at 1:00 PM and RN H on 5/12/2022 at 3:00 PM.

A review of Healthcare Safetyzone Event #239161 revealed documentation authored by Risk Manager N on 5/12/2022 at 5:09 PM, "...Attempted to call patient (Patient #1) back at 4:59 PM today with no answer, will try to contact him/her to follow up when I return to the office next week." On 5/16/2022 at 1:40 PM, "Attempted to call patient again, left general message asking for a return call." On 5/20/2022 at 1:57 PM, "Status...Closed." No further documented follow up communication with Patient #1 was found.

An interview was conducted with Director of Emergency Services D, Education Manager B and Chief Nursing Officer K on 7/6/2022 at 10:40 AM. When asked if a follow up letter should have been sent to Patient #1 since phone contact had not been successful, all 3 staff responded, "Yes."