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Based on interview and record review, the facility failed to investigate a written concern about care received in the facility for 2 (#s 5 and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients who received care in the facility and/or filed grievances with the facility. Findings include:

1. Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a phone call from patient #5 and was concerned about the care she had received in the ED (emergency department) on 9/27/24. The incident report does not show what date the phone call occurred and was classified as "unresolved/referred to leadership for resolution (Grievance)."

Review of patient #5's complaint/grievance form, generated by SIM (Safety Incident Management) showed an entered date of 1/16/25 that was addressed by staff member G. Staff member G had written in the "What is the concerns?" section: ..."I explained that I understood her concerns, and the ED manages acute symptoms ... she understood but still wanted to file a complaint in hopes that in the future communication from healthcare providers and staff can be improved."

Under the "Immediate Actions" section showed:
"-Discussed with patient/family,
-Informed patient/family grievance has been referred for follow up/resolution is pending,
- Referred issue to Director/Manager..." [sic]

The incident report showed a close date of 2/14/25.

A request for the complete investigation of the phone call was requested on 6/17/25 at 9:05 a.m., but the information was not received.

During an interview on 6/17/25 at 1:45 p.m., staff member A stated there was no investigation or documentation related to the incident that involved patient #5.

During an interview on 6/18/25 at 9:30 a.m., staff member D stated he was informed about the concern and talked with his staff, but no education or follow-up was completed or documented.

During an interview on 6/18/25 at 10:09 a.m., staff member G stated she had taken the phone call from patient #5 through the advocacy line to file the complaint. Staff member G stated when a call is received from the advocacy line the goal is to resolve the complaint in real time. Staff member G stated patient #5 had concerns with the quality of care she had received and felt that after she (staff member G) had spoken to patient #5, the concern had been resolved. Staff member G could not remember why she had forwarded the incident for resolution. Staff member G stated she did not consider the complaint a grievance because patient #5 had called the advocacy line and did not submit a written complaint. Staff member G stated there was no further investigation or education provided to staff regarding the complaint.

2. Review of a complaint document filed with the State Survey Agency on 5/30/24 showed the complainant (NF1) had submitted a letter to the facility on 3/30/25, regarding concerns with the care patient #7 had received on 9/22/24.

Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a letter from NF1. In the complaint/grievance log the facility classified the letter as "1. Complaint/For information only."

A request for the complete investigation of the grievance submitted by NF1 was requested on 6/17/25 at 9:05 a.m. The information was not received.

During an interview on 6/17/25 at 1:45 p.m., staff member A stated there was no investigation or documentation related to the grievance for patient #7.

During an interview on 6/17/25 at 2:17 p.m., NF1 stated she had written the letter to the facility because she felt patient #7's patient rights were violated. NF1 stated patient #7 was working in the garden when he suddenly collapsed. NF1 stated a neighbor had witnessed the incident, called 911, and started CPR. NF1 stated when the ambulance arrived they took over CPR and transported patient #7 to the facility. NF1 stated, "[Patient #7] should not have gone to [Facility Name], that is not where we go." NF1 stated the facility never notified her of the passing of patient #7. NF1 stated, "[Hospital Name] notified someone else, and I had to find out from another family member that [Patient #7] had died." NF1 stated patient #7 was sent to the wrong funeral home, and the facility did not follow [Patient #7's] advanced directives, and by not following patient #7's advanced directives, they denied him last rites. NF1 stated, "[Patient #7's] advanced directives were on file with the Montana end-of-life registry, and everybody can access the website." NF1 stated she had never received a phone call or letter from the facility about the letter she had sent. NF1 stated, "As far as I know the letter was ignored."

During an interview on 6/18/25 at 6:15 a.m., staff member F stated patient #7 arrived at the facility via ambulance in cardiac arrest with CPR in progress. Staff member F stated there were no advanced directives on file with the facility. Staff member F stated he had never accessed the end-of-life registry to check for advanced directives. Staff member F stated, "In an emergent situation there is no time to try and locate advanced directives, if they are not on file with the [Facility], and if a patient comes into the department coding, we use implied consent." Staff member F stated patient #7 had family members who had come into the department, and he was able to notify them that patient #7 had passed away. Staff member F stated after the family was notified other staff members then spoke with the family about mortuary arrangements.

Review of patient #7's complaint/grievance form, generated by SIM (Safety Incident Management) showed an entered date of 4/22/25. 23 days after the letter was sent to the facility. The incident showed the letter had been attached to the incident report and sent to staff member B. Under the "Resolution and Outcomes" section it showed the incident had been closed. No investigation information was attached to the incident report.

During an interview on 6/18/25 at 9:09 a.m., staff member B stated, "There was a delay in getting our incidents processed in the reporting database (RL solutions). I did not send out a letter of intent to investigate to the patient's representative. There really was not any investigation conducted. I am to blame for this one, I am not trying to make excuses, but my education, experience, and training were probably not where they should have been at that time. I should have done a better job. There was no education provided to anyone after this incident."

During an interview on 6/18/25 at 9:30 a.m., staff member D stated he was informed about the concern and talked with his staff, but no education or follow-up was completed or documented. Staff member D stated if advanced directives were not on file, they continue as full code status until determined otherwise.

Review of a facility document titled, "Patient Complaint and Grievance Procedures, AD7001," with an effective date of 9/2023, showed:
... "Appropriate personnel must review, investigate, and resolve each grievance within a reasonable time frame.
Definitions:
... Grievance: A formal or informal written or verbal complaint that is made by a patient, or patient representative regarding the patient's care...
... - If a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect, or failure of the organization to comply with one or more CoPs, will be considered a grievance.
... Section 504 Grievance Procedure:
... conduct an investigation of the complaint. This investigation may be informal, but it must be thorough..."

Based on interview and record review, the facility failed to investigate and resolve grievances within a reasonable time frame, for 2 (#s 5 and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients who filed grievances with the facility. Findings include:

1. Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a phone call from patient #5 and was concerned about the care she had received in the ED on 9/27/24.

Review of the facility's incident report showed the incident was entered into the grievance/complaint tracking system on 1/16/25 and had a closed date of 2/14/25. There was no documentation showing an investigation or resolution of the grievance was completed.

2. Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a letter from NF1. In the complaint/grievance log the facility classified the letter as "1. Complaint/For information only."

Review of the facility's incident report showed the complaint was entered into the tracking system on 4/22/25 and closed on 4/22/25. There was no documentation showing an investigation or resolution of the grievance was completed.

During an interview on 6/17/25 at 1:45 p.m., staff member A stated there was no investigation or documentation related to the grievances for patients #5 and #7.

During an interview on 6/17/25 at 2:17 p.m., NF1 stated she had written the letter to the facility on 3/30/25 because she felt patient #7's patient rights were violated. NF1 stated she had never received a phone call or letter from the facility about the letter she had sent. NF1 stated, "As far as I know the letter was ignored."

During an interview on 6/18/25 at 9:09 a.m., staff member B stated, "I did not send out a letter of intent to investigate to either of the patient's or patient representatives. There really was not any investigation conducted. I am to blame for this one. I should have done a better job. I have started to keep better track of timeframe's and when to send letters out."

Review of a facility document titled, "Patient Complaint and Grievance Procedures, AD7001," with an effective date of 9/2023, showed:
... "Policy:
... Appropriate personnel must review, investigate, and resolve each grievance within a reasonable time frame.
... Procedure:
... Every effort is made to resolve grievances within 7 days.
... Documentation:
... [Staff Department] will ensure documentation is completed.
... Grievance procedure:
... a written decision on the grievance no later than 30 days after its filing."

Based on interview and record review, the facility failed to provide the required written resolution for patient grievances for 2 (#s 5 and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients who file grievances with the facility. Findings include:

Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a phone call from patient #5 and was concerned about the care she had received in the ED on 9/27/24. The incident report did not show what date the phone call occurred and was classified as "unresolved/referred to leadership for resolution (Grievance).

During an interview on 6/18/25 at 10:09 a.m., staff member G stated she had taken the phone call from patient #5 through the advocacy line to file the complaint. Staff member G stated when a call is received from the advocacy line the goal is to resolve the complaint in real time. Staff member G stated patient #5 had concerns with the quality of care she had received and felt that after she (staff member G) had spoken to patient #5, the concern had been resolved. Staff member G could not remember why she had forwarded the incident for resolution. Staff member G stated she did not consider the complaint a grievance because patient #5 had called the advocacy line; she did not provide a written complaint. Staff member G stated no resolution letter was sent to patient #5.

2. Review of the facility's complaint and grievance logs dated 8/1/24-3/30/25, showed the facility had received a letter from NF1. In the complaint/grievance log the facility classified the letter as "1. Complaint/For information only."

During an interview on 6/17/25 at 2:17 p.m., NF1 stated she had never received a phone call or letter from the facility about the letter she had sent. NF1 stated, "As far as I know the letter was ignored."

During an interview on 6/18/25 at 9:09 a.m., staff member B stated, "I did not send out a letter of intent to investigate or a letter for resolution to [NF1]. I should have done better with this grievance."

Review of a facility document titled, "Patient Complaint and Grievance Procedures, AD7001, with an effective date of 9/2023, showed:
... "Procedure:
... "For all grievances, a written response must be provided...