HospitalInspections.org

Based on staff interviews and document reviews, it was determined the facility failed to adhere to its policy established for responding to grievances .

The findings included:

A document titled, 2022 Grievance Report for Survey, was reviewed on 1/3/23 and 1/4/23 by the surveyors. The document contained grievances received and entered into the system from 10/1/2022 through the date of the survey. There was no entry in the log of the facility having received a grievance concerning Patient #5.

On 1/4/23 at 1:30 p.m., the surveyors discussed the grievance process with SM #5. SM #5 explained that complaints are related to "non-patient care concerns" and grievances are related to "patient care and safety." SM #5 said that during a conversation with SM #10, SM #10 confirmed speaking with Patient #5's family member by telephone and had "forwarded" the patient care related concern to the ED Medical Director via email. The patient relations staff were unable to confirm if the ED Medical Director or any other provider had followed up with Patient #5's family member. SM #5 acknowledged that the facility did not follow their complaint/grievance process and stated, "our system is broken". SM #5 explained that the individual who received the phone call should have referred the complaint "up to the next level of leadership" until the "concern was resolved". SM #5 confirmed there was no other documentation regarding the grievance and Patient #5's grievance (on behalf of the family member) was never entered into the facility's tracking system.

At 1:41 p.m., SM #5 provided documentation which evidenced that SM #10 emailed the ED Medical Director on 11/4/22 at 2:48 p.m. regarding Patient #5's family member's concerns with care. A follow-up was requested and the family member's phone number was provided. At 8:44 p.m. on 11/4/22, the ED Medical Director responded with, "I'm out of town for the next week--copying [name of provider] for an assist. I know [provider] has a crazy schedule, so if [provider] can't call [patient's family member], I'll call when I return." There was no documentation to confirm if additional follow-up was completed.

On 11/4/22 at 2:02 p.m., SMs #2 and #5 advised the surveyors they were unable to determine if the provider, whom the ED Medical Director forwarded the email too, responded to the grievance. SM #5 advised the patient relations department had failed to enter " 2 complaints and 1 grievance" into the facility's tracking system. The grievance was the one submitted by Patient #5's family member.

The surveyors reviewed a facility document titled, Patient Complaints and Grievances, that reads, in part: " i. Patient Complaints and Grievances shall be documented in the patient feedback system... ii. [Name of facility] shall maintain documentation of all Grievances, copies of its investigations, and responses to patients...".