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Based on staff interview and record review, the facility failed to review and resolve a patient grievance according to facility policy for one applicable patient (Patient #1). Findings include:

Per record review, Patient #1 was admitted to the hospital on 2/7/2018 with multiple electrolyte abnormalities and was treated overnight with IV (by vein) fluids and medication. Per Physician Progress note dated 2/8/2018, Patient #1 was assessed to be in stable and improved condition and felt s/he, "was at baseline health". Per record review, Patient #1's legal guardian was contacted regarding the discharge, and requested to be present at the time of transport from the facility to the nursing home. Patient #1 was discharged and transported to the nursing home prior to the arrival of the legal guardian at the facility on 2/8/2018. On 2/9/2018 Patient #1's legal guardian called the hospital, spoke to the Case Management Director, and expressed dissatisfaction with her lack of participation in Patient #1's discharge process, and stated concerns about the attire Patient #1 was wearing at the time of discharge. Per record review, Patient #1's legal guardian stated the facility was "neglectful" with the attire provided to Patient #1 and dissatisfied that Patient #1 had been transported in her absence. Per Case Management progress note dated 2/9/2018, a secure email message including Patient #1's legal guardian's concerns was submitted to the facility's Patient Experience Specialist and Nursing Director.

The facility policy, "Patient Complaint and Grievances" (approved 1/4/2017) states that, "all concerns or complaints are consistently addressed in a timely and respectful manner". The policy Procedure states under 1.f.) "The appropriate intake resource will take the necessary actions with the complaint and appropriate (facility) staff to investigate and resolve the complaint".

During an interview on 5/9/2018, the facility's Patient Experience Specialist (responsible for the management of the facility's complaint and grievance process) confirmed s/he had received the email message about Patient #1's legal guardian's concerns. However, s/he "did not escalate the concerns to the level of a complaint" because the Director of Case Management and Nursing Director were reviewing the patient representative's concerns. During an interview on 5/8/2018 at 2:00 PM, the Patient Experience Specialist confirmed the concerns reported by Patient #1's legal guardian had not been investigated, reviewed or resolved per facility policy. At the time of the investigation, there was no evidence of a response provided to Patient #1's legal guardian following her phone call to the facility on 2/9/2018.

Based on staff interview and record review, the facility failed to ensure that a response was provided to a grievance within the timeframe identified in the facility's policy for one applicable patient/ patient's representative (Patient #1). Findings include:

Per record review, Patient #1 was admitted to the hospital on 2/7/2018 with multiple electrolyte abnormalities and was treated overnight with IV (by vein) fluids and medication. Per Physician Progress note dated 2/8/2018, Patient #1 was assessed to be in stable and improved condition and felt s/he, "was at baseline health". Per record review, Patient #1's legal guardian was contacted regarding the discharge, and requested to be present at the time he was transported from the facility to the nursing home. Per record review, Patient #1's was discharged and transported to the nursing home prior to the arrival of the legal guardian at the facility on 2/8/2018.

On 2/9/2018 Patient #1's legal guardian called the hospital, spoke to the Case Management Director, and expressed dissatisfaction with her lack of participation in Patient #1's discharge process and stated concerns about the attire s/he was wearing at the time of discharge. Per Case Management progress note dated 2/9/2018, a secure email message with the patient representative's concerns was submitted to the Patient Experience Specialist and Nursing Director from the Case Management Director.

Per facility policy, "Patient Complaints and Grievances" (approved 1/4/2017) "within 10 business days from the receipt of the complaint, a formal written response will be created...unless an acknowledgement letter has been sent requesting additional time for the investigation". "The letter will be mailed to the complainant at the conclusion of the investigation".

During an interview on 5/8/2018 at 2:00 PM, the Patient Experience Specialist confirmed the concerns reported by Patient #1's legal guardian had not been investigated, reviewed or resolved per facility policy. At the time of the investigation, there was no evidence of a written response provided to Patient #1's legal guardian following their phone call to the facility on 2/9/2018.

Based on staff interview and record review, the facility failed to include the patient's representative in the implementation of the discharge plan for one applicable patient (Patient #1). Findings include:

Per record review, Patient #1, has dementia (chronic disorder associated with a decline in memory and cognitive functioning which interferes with daily activities) and other respiratory and cardiac medical conditions. S/he was admitted to the hospital on 2/7/2018 from a nursing home with abnormal levels of electrolytes requiring inpatient treatment. Per interview with Patient #1's legal guardian, Patient #1 was discharged from the hospital back to the nursing home on 2/8/2018 on a very cold day, dressed in a hospital gown covered with blankets. Patient #1's legal guardian requested riding with Patient #1 at the time of discharge, however s/he was sent back to the nursing home alone via a wheelchair accessible bus.

Per review of physician documentation, Patient #1 was admitted for IV (in the vein) fluids and supplements including potassium, calcium and magnesium in order to correct electrolyte imbalances. Per physician documentation, on 2/8/2018, Patient #1 was assessed to be in, "stable and improved" condition and reported s/he was, "at baseline health". The legal guardian, Patient #1's daughter, was notified by the facility's case manager of Patient #1's expected discharge that day. Per Case Management note dated 2/8/2018 at 09:52 AM, "I have called patient's daughter. She will be coming...to ride the bus with patient back to" the nursing home. Per review of Nursing Progress notes, Patient #1's discharge was documented in a Nursing Progress note dated 2/8/2018 at 10:25 AM, stating that a nursing report had been provided to the receiving facility and the patient's condition was stable.

Patient #1's legal guardian was not present as requested at the time of transfer to the receiving facility. Per interview on 5/8/2018 at 11:30 AM , a Registered Nurse assigned to care for Patient #1 stated that Patient #1's daughter arrived at the hospital on 2/8/2018 after Patient #1 had been discharged and left the hospital via a wheelchair accessible vehicle. The Registered Nurse stated s/he, "was not aware" of the legal guardian's request to be present at the time of Patient #1's discharge. Per interview on 5/8/2018 at 9:00 AM, the Case Management Director stated, "we could have done a better job with communication" regarding Patient #1's discharge plan. The Case Management Director confirmed during an interview on 5/8/2018 that Patient #1's legal guardian had not been provided the opportunity to participate in the implementation of Patient #1's discharge plan as requested.