HospitalInspections.org

Based on policy review, Plan of Correction (POC), document review and interview, the facility failed to ensure all patient grievances were investigated timely, included a thorough investigation and written response that included steps taken to investigate the complaint, the results and date of completion for 4 of 6 (Grievance #1, 2,3 and 4) grievances reviewed.

The finding included:

1. Review of the "Patient and/or Patient Representative (Complaint) Grievance" policy revealed, "...PROCEDURE ...D. A copy of the grievance is to be forwarded to the Patient Advocate within 1 day. E. After a thorough investigation by the Department Manager [DM], the facts and actions are to be documented and forwarded to the Patient Advocate...F. Grievances will be reviewed and a response provided, no longer than 7 days. A written response will be sent and will include ...the steps taken to investigate the complaint, the results and date of completion..."

2. Review of the POC dated 11/8/15 revealed, " ...Through approval and review of policies and procedures for...grievances...as well as analysis of the chart audits and establishment of the interventions. The CEO [Chief Executive Officer] & [and] Governing Board will ensure a culture of safety for [name of facility] patients...The Patient Advocate or designee monitors all patient grievances and complaints by tracking the date the grievance/complaint occurred and date it was opened and closed...When individual care issues are identified through a grievance they will be investigated and thorough the investigation measures to insure recurrence do not occur will be implemented. These measures will require specified attention dependent on what the issue is at the time. All Grievances are monitored by the Patient Advocate...The grievance log, along with resolutions, is reviewed weekly...This review includes an analysis of the grievance the investigations and confirmation that the grievances were responded to the patient in writing ... "

3. The facility failed to implement their POC and facility policy as evidenced by the following:

a. Review of Grievance #1 revealed on 11/9/15 Patient #10 complained that an Emergency Department employee contacted the patient's employer informing the employer the patient would change the date of the return to work statement. The patient complained that she was terminated from her job related to this incident.

Review of the 11/9/15 letter from the PA to the patient revealed, "...To ensure that our staff conducts itself in a manner that reflects the high regard that we have for our customers, we have notified the proper entities of your complaint..."

There was no written response to the complainant that included the steps taken to investigate the complaint, the results and date of completion.

b. Review of Grievance #2 revealed on 11/22/15 Patients #11 and #13 complained that Staff #1 was rude, yelled, made rude comments that included profanity to the patients.

Review of the 11/23/15 email revealed the DM spoke with Staff #1 regarding professional and courteous behavior.

Review of the 11/23/15 letter from the PA to the patient revealed, "...To ensure that our staff conducts itself in a manner that reflects the high regard that we have for our customers, we have notified the proper entities of your complaint..."

Review of the grievance log revealed the grievance on behalf of Patient #11 was closed on 11/23/15.

There was no documentation of the actions or investigation steps taken to address the grievance. There was no written response to the complainant that included the steps taken to investigate the complaint, the results and date of completion within 7 days.

In an interview on 12/8/15 at 9:00 AM in the conference room the PA stated she did not realize the complaint was signed by 2 patients and did not send a response to Patient #13. The PA verified there was no documentation the grievance was thoroughly investigated in 7 days and no written response sent to the complainants that included the investigation steps, results and date closed.

In an interview on 12/8/15 at 9:30 AM in the conference room the DM verified there were no documented statements, interventions and timely investigation for this grievance.

c. Review of Grievance #3 revealed on 11/23/15 Patient #9 complained about the time a physician spent on rounds and was not allowed to leave Against Medical Advice (AMA).

In an interview on 12/7/15 at 1:43 PM in the conference room the PA stated the patient was an involuntary admission and would not be eligible for AMA.

There was no documentation a written response was sent to the complainant that included the investigation steps, results and date closed.

d. Review of Grievance #4 revealed on 12/4/15 Patient #7 complained about going outside for fresh air and the programs not being appropriate.

Review of the grievance log revealed the grievance on behalf of Patient #7 was received on 12/7/15 and closed on 12/7/15.

Review of the 12/7/15 letter from the PA to the patient revealed, "...To ensure that our staff conducts itself in a manner that reflects the high regard that we have for our customers, we have notified the proper entities of your complaint..."

There was no documentation a written response sent to the complainant that included the investigation steps, results and date closed.

In an interview on 12/7/15 at 1:17 PM in the conference room the PA stated the grievance was not resolved, even though the log documented the grievance was closed.