HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy and procedure for one of two patients (#5) reviewed for complaints and grievances alleging abuse resulting in the potential for less than optimal outcomes for patient #5. Findings include:

On 3/3/2020 at 1400, review of the Grievance and Complaint Logs was conducted with Patient Relations Staff H and I and revealed patient #5 had filed a complaint on 2/14/2020. At that time Staff I explained that she did not process the complaint. Staff I said Patient Relations Staff J processed the complaint and she would be returning to work on 3/4/2020. Review of the complaint revealed patient #5 reported "the nurse in charge" was rude and spoke to her in a nasty way. The patient also requested in filing her complaint that the manager be notified as well and the "person above her."

On 3/3/2020 at 1415 Staff I explained the complaint was forwarded to Nurse Manager Staff R for investigation and resolution. Staff I provided a closure letter dated 2/26/2020 that acknowledged a grievance had been filed on her (#5's) behalf on 2/17/2020 that addressed the patient's concerns related to the "charge nurse's" comments, and rude and non-caring behaviors. The letter documented the investigation was completed on 2/26/2020 with assurance that appropriate administrative follow-up had taken place. The letter identified Clinical Nurse Manager Staff R as the administrator responsible for the review. However, Staff R was also identified as the "nurse in charge", whose actions triggered the complaint.

On 3/4/2020 at 1100 Staff R was interviewed. She explained that when she received the complaint that she "self disclosed" that it was her. Staff R said she handled it. Staff R was asked to explain if her Director was involved in the resolution of the patient's grievance. She said no she was not involved.

During an interview on 3/4/2020 at 1330, the Director of the Critical Care Unit Staff J said she only became aware of the aforementioned concerns on 3/3/2020. Staff J confirmed the grievance should have gone to her as requested by patient #5.

Review of the facility's "Patient-Family Complaint and Grievance Process" policy dated last revised on 9/2010 documented:
E. The Patient Relations staff will evaluate the complaint/grievance and, as necessary assist in the resolution by explaining hospital policies and procedures, and involve the appropriate management personnel, including administration, to expedite services and/or take corrective action.