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Based on interview and record review, the facility failed to adhere to it's grievance policy for grievances thought to have the potential for risk issues for two (#1 and #2) of five grievances reviewed, resulting in the failure to accurately track and trend patient concerns to identify potential areas for improvement and for potential consumer dissatisfaction related to lack of timely resolution for grievances. Findings include:

On 4/30/18 at approximately 0730, review of a complaint allegation for Patient #1 revealed documentation that Patient #1 was seen in the hospital emergency department (ED) on 2/15/18 for a broken ankle following a fall at home, and was sent home alone by ambulance with a non weight bearing cast and was unable to walk. The allegation documented that a grievance was made to the facility regarding this on 2/19/18. The allegation alleged that a complaint acknowledgement was never received, but a complaint resolution letter was received on 4/13/18, signed by The Physician Director of Quality, Staff M.

On 5/3/18 at approximately 1300, Patient #1's clinical record was reviewed with Staff I and revealed the following: Patient #1 was an 88 year old male who lived alone. Patient #1 fell in his driveway on 2/15/18 and called the Emergency Medical Service (EMS) to take him to the hospital ED. Xrays done in the ED on 2/15/18 documented that Patient #1 had a comminuted (broken into multiple pieces) fracture of the right fibula (shin bone), fracture of the distal fibula (smaller shin bone), displaced fracture (bones separated and not in alignment) of the medial malleolus (ankle) and disruption of the ankle mortise (ankle structure). Patient #1 was sent home alone by ambulance on 2/15/18 with a non weightbearing temporary cast and instructions to follow up with an orthopedic surgeon.

On 4/30/18 at approximately 0800, review of a complaint allegation for Patient #2 revealed documentation that Patient #2's family had made a complaint to the facility that the family's wishes regarding autopsy of Patient #2 were not honored. The allegation documented that the family met with facility administrative staff on 11/22/17 to discuss their grievance with the facility.

On 5/3/18 at approximately 1400, Patient #2's clinical record was reviewed with Staff I and revealed the following: Patient #2 was a 75 year old male who was admitted to the facility on 10/30/17 for a percutaneous endoscopic jejunostomy tube (feeding tube) insertion. Diagnoses included gastroesophageal cancer. The patient expired in hospital on 11/3/17. Documentation revealed the remains of the deceased were transferred to a funeral home and embalmed without autopsy. Documentation indicated that autopsy was requested by the family. No autopsy was done.

On 5/3/18 at approximately 1430, the hospital grievance and complaint log was reviewed with the Director of Patient Experience, Staff M, and the corporate Risk Management Vice President, Staff H and revealed neither patient was documented on either the safety logs or the grievance logs.

On 5/3/18 at approximately 1500, the Physician Director of Quality, Staff M was interviewed and provided two investigation files for review, one for Patient #1's grievance and one for Patient #2's grievance. Staff M reported that she was asked to handle these two risk concerns because the previous (no longer at facility) Medical Director was supposed to take care of them, and they were not completed and no investigation or corrective measures were done before he left. The grievance resolution letter for the complaint regarding Patient #1 was dated 4/13/18, over two months after the grievance was made. The grievance resolution letter for patient #2 was dated 4/13/18. Per the Director of Patient Experience, Staff M the grievance was received on 1/04/18, over three months before the resolution letter was sent.

On 5/3/18 at approximately 1530, Staff M was asked why the two concerns related to Patient #1 and #2 were not on the grievance log. Staff M reported that they were both grievances, and said, " They both were forwarded over to Risk rather than the Grievances because they were considered risks." When asked about this, Staff M reported that she was instructed, " If a patient complaint or grievance is a risk issue we don't handle it in Patient Experience as a grievance. We weren't supposed to enter it on the grievance log. We were told to turn it over to (previous Medical Director) as a Risk issue, and he handled everything from there."

On 5/3/18 at approximately 1535, the corporate Risk Management Vice President, Staff H was interviewed and reported that she did not know about grievances, complaints or adverse events if they were handled by the ex-Medical Director without appearing on the appropriate logs. Staff H stated, "We can't look for trends. I wouldn't have found out about these grievances. I don't see them if they're handled that way. We have some work to do."

On 5/7/18 at 1630, Review of the facility policy entitled, " Patient Complaint and Grievance Management", dated 11/27/17 revealed the following statements, "enter the complaint in the Feedback module of Safety first and inform the patient of the next steps in the resolution process (which includes immediate initiation of an investigation to resolve the issue, a written response to the patient within 7 days providing the status and or resolution regarding the complaint. All Grievances will receive an initial communication (a written response) within 7 days. A second response will be sent within a reasonable time frame. The grievance review process will occur within 10 days of the grievance being filed."