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Based on record review and interview, the facility failed to follow established Grievance Management Process in 1 of 3 grievances reviewed. (ID # 1)

Findings include:

Record review of facility policy titled "Patient Grievance Management" dated June 2023, showed the following:

POLICY

It is the policy of BSLMC to formally receive, review, and respond to complaints and/or grievances from patients or patients' representatives, their family members, and guests of CHI St. Luke's.

DEFINITIONS
* A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or a patient's representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CM'S Conditions of Participation (Cops).

Procedures
3. Management of Grievances

b. following receipt of a written or verbal grievance, the hospital's grievance coordinator or designee reviews, documents, and coordinates the investigation...



Record review of Return Receipt of complaint letter from patient (ID#1) to facility showed a facility stamped acknowledgement of receipt of the letter dated 3/8/2024.


Interview with facility grievance coordinator (ID# 59) on 4/17/2024 at 11:58 AM stated that there was no documented grievance for patient (ID #1). She was able to verify complaint and grievance procedures. She stated that one items are received via "mail" there is a box that they are put in and retrieved by her department. At that point they get logged in. Any complaints/ Grievances that are received by Administration are forwarded to her department, get logged in and follow the process.

Interview with facility Director of Quality (ID # 55) on 4/17/2024 at 1:00 PM verified the letter was received in the mail room and was routed to administration as it was addressed to the facility CEO. She stated that the administrative staff was unfamiliar with the name on the letter (previous CEO) and the letter was returned to sender.