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Based on record review and interview, the hospital failed to ensure inpatient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by the hospital staff's failure to correctly identify a patient complaint (#2) as a grievance and failure to respond to the grievance in writing, as per their hospital policy, for 1 (#2) of 2 (#1,#2) patients reviewed for complaints/grievances.

Findings:

Review of the hospital policy titled, Patient Complaint, Grievance, and Service Recovery, revealed in part:
I. Purpose: To provide patients or patients' representatives with a timely and efficient process for managing complaints and grievances regarding patient care.
III. Definition of Terms: A. Complaint: Is a concern represented by a patient or patient's representative that can be addressed and/or resolved in a timely manner by staff members who are present at the time of the complaint. "Staff Present" includes those individuals close to the complaint situation or who can be at the patient's location in a timely manner to address and/or resolve the patient's complaint. Generally, complaints can be resolved timely while the patient is still receiving care in the hospital.
B. Patient Grievance: Is a written or verbal complaint made to the hospital by a patient or the patient's representative regarding the patient's care, abuse, or neglect issues related to the facility's compliance with the CMS Conditions of Participation. This includes when the verbal complaint about patient care is not addressed/resolved to the satisfaction of the patient or patient's representative while the patient is still receiving care at the facility. All complaints that cannot be resolved immediately at the time of the complaint by staff will be addressed as a grievance. Further review revealed regardless of the form in which a complaint is received, whenever the patient or the patient's representative requests a response from the facility, the issue is a grievance.

Review of documentation presented by S3NsgDir revealed a family member of Patient #2 had called in a complaint alleging that no one had gone into Patient #2's room for hours to check on her prior to the patient's transfer to ICU, due to a decline in her condition, on the evening of 7/4/16.

In an interview on 8/17/17 at 8:40 a.m. with S4NsgMgr, she confirmed she had received a complaint from a family member of Patient #2 alleging that no one had gone into the patient's room for hours to check on her prior to the patient's transfer to ICU. S4NsgMgr reported the family member had indicated family was with the patient all day and nobody had ever rounded on the patient. S4NsgMgr further reported she had called the family member (complainant) back, as requested by the complainant, and discussed the results of her investigation into her allegations regarding Patient #2's care. S4NsgMgr said the family member thanked her for calling her back and indicated she still believed Patient #2 had not received the care she deserved. S4NsgMgr confirmed she had called the complainant back but had not responded in writing.

In an interview on 8/17/17 at 8:50 a.m. with S2RiskMgr, she confirmed she had not received notice of the allegation of neglect in the care of Patient #2. S2RiskMgr indicated the complaint had been investigated by S4NsgMgr who had received the complaint. S2RiskMgr acknowledged further investigation had been required and that would have been classified as a grievance by definition. She also acknowledged the hospital policy was to respond to grievances in writing.

Based on record review and interview, the hospital failed to report an allegation of neglect to Louisiana Department of Health within 24 hours of receipt of the allegation for 1 (#2) of 2 (#2,#5) sampled patients reviewed for complaints/grievances alleging neglect or abuse of the patient by hospital staff.

Findings:

Review of the hospital policy titled "Patient Complaint, Grievance, and Service Recovery Policy", presented as a current policy by S2RiskMgr, revealed that a patient grievance is a written or verbal complaint made to the hospital by a patient or the patient's representative regarding the patient's care, abuse, or neglect issues related to the facility's compliance with the CMS Conditions of Participation. This includes when the verbal complaint about patient care is not addressed/resolved to the satisfaction of the patient or patient's representative while the patient is still receiving care at the facility. All complaints that cannot be resolved immediately at the time of the complaint by staff will be addressed as a grievance. Further review revealed regardless of the form in which a complaint is received, whenever the patient or the patient's representative requests a response from the facility, the issue is a grievance.

Review of the form utilized by the hospital to report allegations of abuse and neglect to LDH- HSS revealed the following, in part: Hospital Abuse/Neglect Initial Report: Fax completed form within 24 hours of awareness of the allegation to LDH-HSS.

In an interview on 8/15/17 at 1:30 p.m. with S2RiskMgr, she confirmed the hospital self reported allegations of abuse and neglect to LDH-HSS.

Review of documentation presented by S3NsgDir revealed a family member of Patient #2 had called in a complaint alleging that no one had gone into Patient #2's room for hours to check on her prior to the patient's transfer to ICU due to a decline in her condition.

In an interview on 8/17/17 at 8:40 a.m. with S4NsgMgr, she confirmed she had received a complaint from a family member of Patient #2 alleging that no one had gone into the patient's room for hours to check on her prior to the patient's transfer to ICU. S4NsgMgr reported the family member had indicated family was with the patient all day and nobody had ever rounded on the patient. S4NsgMgr further reported she had called the family member back and discussed the results of her investigation of her allegations regarding Patient #2's care. S4NsgMgr said the family member thanked her for calling her back and indicated she still believed Patient #2 had not received the care she deserved.

In an interview on 8/17/17 at 8:50 a.m. with S2RiskMgr, she confirmed the hospital staff had not reported the above referenced allegations of neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of discovery. She indicated she had not received notice of the allegation of neglect in the care of Patient #2. S2RiskMgr indicated the complaint had been investigated by S4NsgMgr (the staff member who had received the complaint).