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Based on interview and record review, the facility failed to ensure the effective operation of the grievance process when a complaint involving patient care was not handled as a grievance as the facility policy required for 1 of 5 (Patient #1) patient grievances reviewed.

Findings include:

Review of facility complaint and grievance logs for November and December 2022 and January 2023 reflected no complaint or grievance made on behalf of Patient #1.

During an interview on the morning of 2/8/23, Staff #3, Patient Safety Officer stated "the patient's [Patient #1] son sent an email 12/2/22 to the ICU (Intensive Care Unit) Director complaining about the care his mother received while in the PCU (Progressive Care Unit). The ICU Director forwarded the email to [Staff #5], PCU Director that same day. [Staff #5], PCU Director, spoke to the son on 12/6/22. [Staff #5] then forwarded the complaint to me 12/6/22 and I missed it, I'll be honest with you. This was not documented as a grievance or complaint."

Review of a printed email chain provided by the facility from Patient #1's son to Staff #8, ICU (Intensive Care Unit) Director dated 12/6/22 at 12:39 pm reflected "I just wanted to reach out as we have not yet been contacted by the PCU (Progressive Care Unit) director as of now ..."
From Staff #8, ICU (Intensive Care Unit) Director 12/6/2022 at 12:42 pm reflected "Hi [Staff #5 PCU Director] this is the son from last week. I know you're with your mom today but wanted to shift this to you so you can hopefully reach out to this son soon. He's wanting a follow-up. I spoke with him Friday, but he still requested to speak with you ..."
From Staff #5, (PCU Director) to Staff #3 (Patient Safety Officer) Subject: Follow up dated 12/6/22 at 2:28 pm reflected "I called the son and apologized. He asked me questions about the fall itself ...Because she was transferred to ICU and has not returned, I never had a chance to follow up with her [Patient #1] ..."

Review of the facility policy titled "Patient Complaints/Grievances" (Governing Body approved 2/27/2020) reflected the following in part:
"I. Scope: This policy applies to The Hospitals of Providence Memorial Campus and all its off-campus departments ('Hospital').
II. Purpose: This policy outlines the process for review and management of patient complaints and grievances as prescribed in 428.13 (a) of the Conditions of Participation (COP) and Joint Commission Standards.
III. Definitions:
A. 'Complaint' means an oral or written expression of displeasure or dissatisfaction with service received that can be immediately resolved by staff present.
B. 'Grievance' is a formal written or verbal complaint that is made to the hospital by a patient, or the patient's representative (these include any request that their complaint be handled as a formal grievance with a response). Grievances include but are not limited to complaints made about any of the following:
1. The patient's care when not able to be resolved by staff present (i.e. requires further investigation or additional action for resolution at a later time or another party).
2. Abuse or neglect.
3. The hospitals compliance with the CMS conditions of participation.
4. Medicare beneficiary billing complaints if related to rights and limitations provided by 42 CFR 489 (i.e.-inappropriate billing or collections, issues related to violations secondary to age, disability, civil rights, coverage decisions or any issues related to appropriate admission, transfer or discharge) ...
IV. Policy: The patient shall have the ability to file a complaint or grievance as part of the patient rights process and in compliance with the Medicare COP and Joint Commission Standards. Patients registering complaints and/or grievances shall not be subjected to retaliation and/or barriers to service. The Hospital's process for managing complaints and grievances must incorporate the following objectives:
A. Provide patients with a mechanism for filing complaints and grievances without fear of retaliation an/or barriers to service.
B. Provide patients with information about the mechanism to file a complaint or grievance with the hospital, the Texas Department of Health and the Joint Commission or, in the case of complaint regarding quality of care, disagreement with a coverage decision, or appeal of a premature discharge, the TMF Health Quality Institute.
C. Provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by patients and/or patient representatives.
D. Provide an on-going system for monitoring and trending patient complaints and grievances.
V. Procedure:
A. Patient Notification: The Hospital will inform patients, in writing, of their right to make complaints and grievances and the mechanism to do so during the registration/admitting process.
B. Patient Complaints:
1. Staff shall encourage patients to express any complaints or concerns to the individual involved. These may be resolved by the appropriate staff present. Complaints that have not been resolved by staff present (i.e. requires further investigation or additional action for resolution at a later time or by another party) will be managed as a grievance (see B-1.)
2. The Hospital Quality Management Department shall incorporate patient complaints into the complaint/grievance data set for aggregation, analysis, and reporting quarterly to the designated Grievance Committee. Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Commitee, the Medical Staff Quality Improvement Committee, Medical Executive Committee (MEC), and Governing Board.
C. Patient Grievance:
1. Complaints meeting the definition of a grievance will be forwarded to the manager/director of the affected department for investigation and resolution.
2. If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director shall forward a copy of the Patient and Family Complaint/Grievance report to the Director, Clinical Quality Improvement (DCQI) or the Patient Safety Officer for action. The DCQI/Patient Safety Officer shall enact the bill hold process and complete an event report ...
3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified o the response time. Grievances should be resolved and the patient notified of the response in 7 days. (Note: allegations of abuse or neglect will be managed in accordance with time frame of policy COMP-RCC 4.60). If the resolution of the grievance is determined to take longer than seven days, the Grievance Committee or designess will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a 'Deferral Letter'). No more than seven days shall elapse before a response is sent to the patient. If a grievance is made by a patient's attorney, hospital operations counsel or litigation claims person before any written response to the grievance, including a deferral letter or final letter is given. As stated above, a Notice of Malpractice Suit is not considered a grievance.
4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and the patient's legal representative understands within 30 days. The hospital may use additional tools to resolve the grievance such as a meeting with the patient or family. The written response will contain the following minimum elements:
" Date of receipt of Grievance
" Name of the Hospital contact person for patient follow up if needed
" Steps taken to investigate and results
" Date of investigation completion
5. A Grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf. When there are situation where the hospital has taken appropriate and responsible actions to resolve the Grievance and the patient remains unsatisfied, the hospital may consider the Grievance closed. All documentation of patient communication (i.e., letters, responses) will be maintained by the Patient Safety Officer.
6. The Patient Safety Officer will maintain a log that provides response to the patient (see Attachment A). The Hospital's Quality Management department will incorporate grievances into the complaint/grievance data set, which whill be aggregated, analyzed and reported quarterly to the designated Grievance Committee, Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Committee, MEC, and the Governing Board.
E. (sic) Responsible Person: The governing body is responsible for ensuring that all individuals adhere to the requirements of this policy, these procedures are implemented and followed at the Hospital and that instances of non-compliance with this policy are reported to the Chief Operating Officer.
F. Auditing and Monitoring: The hospital Quality Management Department in collaboration with the Patient Safety Officer are responsible for auditing and monitoring compliance to this policy no less than quarterly through review of logs and required documentation.
G. Enforcement: All staff whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, including the Medical Staff Bylaws, Rules, and Regulations.
VI. References:
-2018 Medicare Conditions of Participation 42 CFR 482.13(a)
-The Joint Commission 2020 Hospital Accreditation Standard RI.01.07.01
VII. Attachments:
-Attachment A: Suggested Minimum Elements on the Grievance Log
Attachment A
CO-2.004A Suggested Minimum Elements on the Grievance Log
" Date of Grievance
" Tracking number or identification
" Type of Grievance
" Location/Department
" Person assigned to investigate
" Dates response letter sent (7 days and 30 days as appropriate)
" Comments"

Despite several verbal and written complaints made on behalf of Patient #1, the facility provided no information to the patient or complainant regarding the steps taken on behalf of the patient to investigate the complaint or any results of the
investigation.