HospitalInspections.org

Based on record reviews and interviews, the hospital failed to effectively address a grievance for 1 (#5) of 5 (#1-#5) patients sampled as evidenced by the hospital failing to enter the grievance into the hospital approved electronic occurrence reporting system as per policy and procedure.
Findings:

Review of the policy and procedure titled, "Patient Complaints and Grievances" revealed, in part, the hospital provides a mechanism for receiving, responding and prompt resolution of complaints and grievances regarding patient services or care issues complaint. A patient grievance (formal complaint) is a written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with regulatory standards. Patient complaints that are considered grievances also include situations where a patient or patient's representative telephones the hospital with a complaint regarding a care provided, abuse or neglect or failure to comply with Conditions of Participation. The hospital will uphold the right of each patient or patient's representative to voice a complaint or concern.

Review or the policy and procedure titled, "Patient Complaint and Grievance Procedure" revealed, in part, the Patient Advocacy Experience Department tracking of patient complaints and grievances supporting the involved leaders for resolution and follow up in writing with the patient or patient's representative for all grievances. The patient or their representative may voice complaints in a variety of ways. Whether complaints are submitted in writing or given verbally will be documented in the hospital approved electronic occurrence reporting system by the party receiving the complaint. The party receiving the complaint should document actions taken and if the complaint was resolved at the time the complaint was placed. The patient should have reasonable expectation of care and services and the facility should address those expectations in a timely, reasonable and consistent manner.

Review of the medical record revealed Patient #5 was admitted to the Emergency Department (ED) on 09/17/2022 at 7:33 p.m. Subsequently, at 9:19 p.m., Patient #5 was placed on a Physician's Emergency Certificate related to the preliminary diagnosis of suicidal ideation with an order for every 15 minute observation safety checks. Patient #5 was ordered a regular diet. On 09/19/2022 at 7:00 p.m., Patient #5 was transferred to an acute psychiatric facility.

Review of the medical record revealed on 09/18/2022 at 7:46 p.m., Patient #5's guardian contacted S7RN3 telephonically to verbally inform the hospital that the guardian viewed social media posts of Patient #5 and visitors "goofing off" in Patient #5's room while being treated in the ED. S7RN3 was no longer employed by the hospital.

Review of the hospital approved electronic occurrence reporting system revealed S7RN3 did not enter the complaint as per policy and procedure.

Review of the complaint and grievance logs revealed no complaints or grievances filed by or on behalf of Patient #5 while a patient in the ED.

In interview on 9/29/22 at 1:55 p.m., S3RN indicated there was a hospital approved electronic occurrence reporting system that all staff access to document an occurrence. S3RN indicated there have been times when it was discovered a complaint or grievance had not been entered into the system which resulted in re-education to the staff involved.

In interview on 09/29/2022 at 2:00 p.m., S3RN reviewed the logs and verified there was no evidence of a complaint or grievance filed by or on behalf of Patient #5.

In interview on 09/28/2022 at 10:24 a.m., S6RN2 recalled meeting with Patient #5's father who voiced concerns and shared the social media posts regarding Patient #5 while being treated in the Emergency Department. S6RN2 further indicated Patient #5's father complained about the patient eating take-out food while being treated in the ED. S6RN2 stated that he intended to document the complaint in the hospital approved electronic system, but forgot to do so.

Review of the human resource file of S6RN2 revealed job duty goals including to address any patient concerns/complaints in real time, notify Nurse Supervisor if needed and document in electronic system pertinent details and actions taken.

Review of the orientation agenda for nursing staff revealed orientation included, in part, an agenda item titled, "Occurrence Report/Quantros".

In interview on 09/28/2022 at 10:30 a.m., S5RN1 and S4RC verified that S6RN2 should have entered the father's grievance into the hospital approved electronic system.