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MEMORIAL MEDICAL CENTER 701 N FIRST ST SPRINGFIELD, IL 62781 Feb. 5, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, it was determined the Hospital failed to clearly define a patient grievance to ensure a process for resolution was in place. This has the potential to affect all patients/caregivers receiving care by the Hospital.

Findings include:

1. The policy titled "Customer Complaint/Grievance Management" (revised 9/15) was reviewed on 2/5/16. a) The policy defined a complaint as a concern or issue (usually minor in nature) expressed by the patient or patient's representative that can be resolved in a timely manner during the patient's episode of care. The policy defined a grievance as a "written or verbal complaint (when a verbal complaint is not resolved in a timely manner during the patient's episode of care) that is made by a patient, or the patient's representative, regarding the patient's care or issues.... An allegation of abuse or neglect reported either during the patient's stay..." The policy failed to define that if a complaint cannot be resolved at the time of the complaint, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance.
b) The policy stated grievances will be handled through the Customer Service Department and the Customer Service Representative mail the complainant a response letter or final resolution letter. The policy failed to define what needs to be achieved to consider a grievance resolved.
The cumulative effect of not defining a complaint versus a grievance, ensuring complaints that meet the criteria are elevated to a grievance and appropriately resolved as to when the complainant is satisfied with the actions taken on their behalf demonstrates a lack of process for ensuring complaint/grievances are resolved promptly.

2. The Grievance Review and Resolution Committee meeting minutes (DRAFT) dated 12/1/15 were reviewed on 2/5/16. The meeting minutes lack quality monitoring of the complaint and grievance log to ensure complaints that are not resolved at the time of the complaint are elevated to a grievance and resolved appropriately.

3. During an interview on 2/5/16 at approximately 1:30 PM, E#1 (Assistant Director of Safety and Accreditation) stated the policy allowed a complaint to stay a complaint if it was resolved during the patients stay. E#1 stated some patients are in the hospital for many weeks therefore a timeframe should be defined in the policy as to when to elevate the complaint to a grievance. E#1 stated the Customer Service representative decides when a grievance is resolved.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined in 1 of 1 patient (Pt #2) clinical record reviewed, the Hospital failed to ensure an effective operation of the grievance process. This has the potential to affect all patients/caregivers receiving care by the Hospital.

Findings include:

1. The policy titled 'Customer Complaint/Grievance Management" (revised 9/15) was reviewed on 2/5/16. The policy stated "Grievance Management A. Grievances will be handled through the Customer Service Department... C... A Customer Service Department representative, upon receipt of the grievance, will take ownership of the grievance... Complaint/Grievance Review Reporting Process A. On behalf of the... Board of Directors.. Grievance Review and Resolution Committee is responsible for the effective management of the grievance process which includes the review and resolution of patient grievances"

2. The clinical record of Pt #2 was reviewed on 2/3/16. Pt #2 was admitted on [DATE] for a right colon resection due to colon cancer.

3. A Safety Event notification System for Organizational Reliability (SENSOR) report and complaint file for Pt #2 was reviewed on 2/5/16. The report noted an entry by E#27 (Customer Service Department Representative) on 10/26/15 at 2:43 PM to E#28 (Nurse Manager) indicating a complaint was received on this day in person by Pt #2's spouse and Pt #2 was currently on E#28's unit. The report noted a summary of the complaint (abuse) and requested E#28 to follow up with the complainant per the complainant's request. The report lacked any follow up documentation as to the investigation or actions taken until 12/3/15 when an entry by E#27 to E#28 and E#26 (Manager of Security) indicated that Pt #2's spouse (complainant) had reached out to the E#2 (Executive Vice President/Chief Operating Officer) and reported there had not been any follow up from the previous complaint on 10/26/15. The 12/3/15 entry also noted that E#26 had not followed up with the complainant per the complainants request. The report noted an entry on 12/9/15 at 9:23 AM by E#12 (Registered Nurse caring for Pt #2 during the alleged event) to E#27 and E#28 stating "Sorry this slipped my mind" and summarized the event. An entry "A" final resolution letter authored by E#28 was dated as sent on 12/14/15, 8 weeks after the complaint was received.

4. During a phone interview on 2/5/16 at approximately 3:00 PM with E#29 (Director of Security), E#26 stated there had been no follow up with the complainant and the staff member involved had not been identified as of this date.

5. During an interview on 2/5/16 at approximately 1:00 PM, E#28 stated "I discussed the issues with (the complainant) the next day. I thought it was taken care... I didn't communicate anything with E#26. That's not my department..." E#28 stated E#13 (Certified Nurse Aid caring for Pt #2 during the alleged event) had not been interviewed although a message was left for her to return a call today at 12:30 PM.

6. During an interview on 2/5/16 at approximately 2:30 PM, E#1 (Assistant Director of Safety and Accreditation) stated "It seems like there was some communication with (the complainant) and each person thought the other person was going to follow up... It seems that more allegations were made by the complainant and if they (staff) had documented in the SENSOR system the Customer Service Representative may have considered this event more of a priority." E#1 verbally agreed the Customer Service Representative should have ensured the investigations were completed (staff identified and interviewed) and documented prior to considering the grievance resolved. E#1 stated every complaint and grievance is not reviewed to ensure compliance with the steps although the Customer Service Department report trends and length of time to resolution to the Complaint and Grievance Committee who meets semi annually.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined in 1 of 1 patient (Pt #2) clinical record reviewed, the hospital failed to ensure the grievance was reviewed, investigated and resolved with in a reasonable time frame. This has the potential to affect all patients/caregivers receiving care by the Hospital.

Findings include:

1. The policy titled "Customer Complaint/Grievance Management" (revised on 9/15) was reviewed on 2/5/16. The policy stated "Grievance: A written or verbal complaint... that is made by a patient, or the patient's representative, regarding the patient's care... An allegation of abuse or neglect...Every effort will be made to review, investigate and resolve grievances as expeditiously as possible... The Customer Service Department representative, upon receipt of the grievance will...document its receipt into the SENSOR Event Reporting System. Steps taken during the investigation to resolve the grievance will also be documented in the SENSOR... In response to receiving a grievance a "Response" letter will be mailed... within 7 calendar days... A final "Resolution" letter will be mailed to the complainant within the response letter's stated timeframe... If for any reason the grievance cannot be thoroughly investigated and resolved within the timeframe stated in the 'Response' letter, an 'Intermediate' letter will be sent that includes: The new estimated timeframe for investigating and resolving the grievance.

2. The clinical record of Pt #2 was reviewed on 2/3/16. Pt #2 was admitted on [DATE] for a right colon resection due to colon cancer.

3. A Safety Event notification System for Organizational Reliability (SENSOR) report and complaint file for Pt #2 was reviewed on 2/5/16. The report noted an entry by E#27 (Customer Service Department Representative) on 10/26/15 at 2:43 PM to E#28 (Nurse Manager) indicating a complaint was received on this day in person by Pt #2's spouse and Pt #2 was currently on E#28's unit. The report noted a summary of the complaint (abuse) and requested E#28 to follow up with the complainant per the complainant's request. The report lacked any follow up documentation as to the investigation or actions taken until 12/3/15 when an entry by E#27 to E#28 and E#26 (Manager of Security) indicated that Pt #2's spouse (complainant) had reached out to the E#2 (Executive Vice President/Chief Operating Officer) and reported there had not been any follow up from the previous complaint on 10/26/15. The SENSOR report and the file lacked evidence a Response letter or Intermediate letter was mailed per the 7 day policy requirement. A final resolution letter authored by E#28 was dated as sent on 12/14/15, 8 weeks after the complaint was received.

4. The Grievance Review and Resolution Committee Meeting Minutes (DRAFT) dated 12/1/15 were reviewed on 2/5/16. The meeting minutes state the average time to provide formal written resolution to received grievances was 10.8 days.

5. During an interview on 2/5/16 at approximately 1:30 PM, E#1 (Assistant Director Safety and Accreditation) verbally agreed an investigation had not been completed and resolved in a timely manner.