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Based on document review, and staff interviews, in one (1) of eight (8) grievance files reviewed, the facility failed to provide the complainant with a written response outlining the steps taken to investigate the grievance, the results of investigation, and the date of completion of the investigations.

Findings include:

The facility's policy titled "Complaint and Grievance Policy" which was last reviewed 3/2022 states the following:

Patient Relations will complete a written response of the hospital's findings. Each written response will include the following information:
a. The name of the hospital contact person (signature);
b. The steps taken to investigate the grievance;
c. the results of the internal review;
d. The date of the completion (the date of the letter);
e. New York State Department of Health- Complaint Unit Hotline telephone number and address.

Review of grievance #1 revealed that on 11/7/21, a family member (complainant) of a patient expressed concerns regarding the care provided to the patient. The facility categorized the complaint as "Quality of Care, Accident/Injury. Subcategories: Quality of care/Treatment: Unsatisfactory Outcome, Standard of care not met, Provision of care."

The facility conducted a meeting with the patient's family on 11/10/21. After the meeting the patient's daughter sent a letter to the facility, which was not dated, in which she requested to know what happened to her mother on 11/7/21 between the time her nurse took her lunch break at 12:06 PM and when the doctors coded her at 12:52 PM. The complainant asked the following questions regarding the incident:

1. What time the O2 tube was off?
2. How long the O2 tube was off before her heart stop?
3. What happened when the O2 saturation drops and when it alarms?
4. Anyone attended to my mother when her O2 saturation drops? Her room was right across the nursing station. Was there a patient care technician assigned to my mother?
5. What was the O2 level (setting) my mom was on? I also asked about the O2 weaning off procedure, which was not shared during the meeting.
6. At what time my mom's heart stop?
7. How long did her heart stopped before she was found and coded?

In the facility's final response dated 12/6/21, they stated that an extensive review was conducted and again offered apologies. They provided a list of contacts for the New York State Department of Health, The Joint Commission and Medicare Quality Improvement Livanta.

The letter did not include any response to the complainant's seven (7) questions regarding the quality of care provided to the patient. The investigative steps, date of completion of the investigation and the outcome of the investigation were not documented in the response letter.

This finding was shared with Staff A, Chief Regulatory Officer on 5/12/2022 at 3:40 PM.