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Based on record review and interview the facility failed to follow it's grievance policy to fully respond to and resolve 1 grievance (Patient #1) in 1 of 2 grievance's reviewed.

Findings Include:

Review of Facility Policy #3PE3E66MX2CW-2-1227, last reviewed 09/30/2023, titled, "Patient Complaint and Grievance Resolution Policy revealed, "Definitions:....Grievance: In ....the outpatient department setting, a grievance may be presented by the patient....a grievance is defined as:....An allegation of abuse, neglect or mistreatment. 3.3 Complaints and Grievances---Hospital:...b. Grievance Investigation, Review, and Timelines: A patient experience team member will be assigned to address the grievance....Patient experience team members will involve others in the investigation and review process with resolution to be determined and communicated to the patient as soon as possible....If the grievance is resolved within seven (7) business days, a resolution letter is issued. If a complicated grievance is not resolved within seven (7) business days, the patient will be informed via letter that the investigation is ongoing....If a complicated grievance is not resolved within thirty (30) business days, the patient will be informed in writing that the investigation is ongoing...For grievances alleging abuse, neglect, or caregiver misconduct, an investigation will be conducted.....Those involved in the review of the grievance will constitute an ad-hoc grievance committee to review and resolve the grievance. The ad-hoc grievance committee will facilitate written communication to the patient that reflects the resolution of the concern.....Response and resolution timeline remains the same. c. Decision and Resolution Letter: All grievances will be reviewed by the local Grievance Committee.....A final written resolution letter will be sent to the patient....All the following shall be included in the final written response to the patient: The name of the hospital contact person who managed the grievance process....clear statement of the patient complaint and the steps taken on behalf of the individual to investigate the complaint; information relevant to the investigation; a clear statement of the determination for each issue and the basis for the determination, including any specific actions or adjustments recommended for resolving the identified issues; The date the grievance process was completed, information related to the appeal process. A copy of the final written response regarding resolution of the patient's grievance will be documented in the incident reporting system and will be given to the patient."

Review of Grievance documented by ED Manager F, filed by Patient #1 on 07/19/2023 revealed, ED Manager F received a phone call from Pt. #1 indicating that they were seen for STI (Sexual Transmission Infection) testing. While Pt. #1 was in the triage office, they were emotional and Staff A proceeded to hug and kiss them on the head. Pt. #1 stated the hug turned into what they felt was inappropriate touching or groping. Pt. #1 went back to the ED after the event happened and was later escorted by Staff A back to urgent care to be treated. Pt. #1 stated that (Staff A) texted them multiple times and added them on snapchat requesting pictures of them and sending pictures of (himself/herself). Pt. #1 is requesting that they would like the incident fully investigated and that they be kept updated on the progress of the investigation and the findings/outcome.

On 08/09/2023 at 8:15 AM during review of the caregiver investigation completed for Staff A, when asked for the follow up to the patient for this grievance, Manager B stated, "No letters were sent to (Him/Her) for the complaint. According to the policy of caregiver misconduct reporting it would be sent if deemed appropriate." When asked why wasn't the patient informed of the outcome, and a letter sent within 7 days per the grievance policy, B stated, "I would assume they should receive a letter and I would expect it if they asked for follow up. These letters come from patient experience." When asked how can patient experience send a letter if they aren't involved, B stated, "I totally get it."

On 08/09/2023 at 12:45 PM Manager B produced a letter addressed to Patient #1 dated 08/09/2023, when asked if no response had been made to patient #1 after the grievance made on 07/19/2023, B stated, "Correct. It will be sent tomorrow."

On 08/09/2023 at 2:00 PM in an interview with Quality Manager B when asked to clarify the process for grievance follow up and caregiver misconduct reporting and who is involved, B stated, "For CMC (Caregiver Misconduct) investigations an RL (Incident Report) solutions is filled out and it goes to risk, it doesn't go to grievance." When asked if this was confusing which process to follow, B stated, " Correct, it gets lost between these two, that is definitely where the fall out happens."

Based on interview and record review the facility failed to follow their orientation policy to ensure staff receive system and department orientation in 2 (Staff C and Staff E) out of a total universe of 6 personnel files reviewed.

Findings include:

Review of facility policy #4FAR5N4RSFP7-1560551054-21, last reviewed 10/10/2021, titled, "Orientation Policy," revealed, "System orientation is required of all newly hired.....staff...All new staff are expected to attend all sessions as assigned."

Review of facility policy #HNYVD5CFV27X-9-49, last reviewed 05/02/2022, titled, "Department Orientation Standards Policy," revealed, "Purpose statement: To provide system-wide orientation standards for all non-credentialed staff within their unit/department. Orientation checklists must be completed for all non-credentialed staff upon hire and/or transfer to another department or role....Record Management: Managers are responsible for developing and maintaining a storage process for employee orientation files....Electronic and paper file must be accessible at any given time....3 years of employees' orientation/ongoing education/ competencies must be accessible for accreditation purposes."

On 08/09/2023 from 08:40 - 09:25 AM during Personnel File Review with HR Assistant O, observed Personnel Files for ED RN's C and E were missing system and department orientation skills checklists. There was no evidence that Staff C or Staff E had completed orientation prior to working in the ED. These findings were confirmed by Manager B on 08/09/2023 at 2:00 PM.

On 08/09/2023 at 2:00 PM Quality Manager B stated, "We cannot find a signed or completed orientation packet for both (Staff C and Staff E) The ones that we pulled up are blank and there is nothing else. "