The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on review of policy and procedure, grievance reports, medical record review and staff interview the facility staff failed to follow-up and/or provide resolution to a grievance within an established timeframe in 1 of 3 grievance files reviewed. (Patient #3)

Findings included:

Review of policy, "Patient Complaints/ Grievances", last revised 11/2017 revealed, "...Grievance- A formal or informal written or verbal complaint that is made to a (hospital name) by a patient or the patient representative. These include, but are not limited to, the patients care, abuse, neglect, issues related to the entity's compliance with regulatory standards, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. ... A formal or informal written or verbal complaint that is received by (hospital name) regarding a patient that is no longer located within a (name hospital) is determined to be a grievance for the purposes of this policy. A grievance about situations that could endanger the patient, such as neglect or abuse, will immediately be submitted to Risk Management for review and action. ... Grievance Management Process: ... Ensure the grievance is documented in the Grievance database; Acknowledge receipt of grievance, in writing, to patient/patient representative within 7 calendar days (on average); Request what action the patient/ patient representative would like as resolution for the grievance and documents it in the database....If not resolved within 7 calendar days, a follow up letter that addresses the grievance and resolution will be sent within 30 calendar days (on average); Additional follow-up letters that address the grievance and resolution will be sent every 30 calendar days until the grievance is resolved. All letters/written responses will be forwarded to the Experienced Team Member for documentation in the grievance database ..."

Review of the grievance file for Patient #3 revealed telephone notification of a grievance on 02/16/2018 related to assessment and diagnostics after a fall. Review revealed an acknowledgement letter was sent on 02/23/2018 (7 days after facility notification) stating,"...Please be assured that I will have the care reviewed in response to these concerns." Review revealed no follow-up letter addressing the grievance and/or resolution was available for review. Continued review revealed no follow-up letters indicating the investigation was ongoing available for review.

Record review on 05/30/2018 revealed Patient #3 was discharged from the hospital to a rehabilitation facility on 02/16/2018 at 1248. On 02/16/2018 at 1837 Patient #3 presented to Emergency Department (ED) via (emergency medical services) EMS from rehabilitation with complaint of hip pain and inability to bear weight. Continue review revealed patient had a fractured right hip per X-Ray. Continued review revealed Patient #3 was not admitted to the hospital. Review revealed the patient was discharged back to the nursing facility for pain management after the hip fracture was diagnosed because the patient was not a surgical candidate.

Interview on 05/30/2018 at 1605 with a Risk Manager revealed a family member notified the nursing supervisor on 02/16/ 2018 of patient #3`s return to the ED with concerns that patient was not appropriately evaluated and no one had known patients hip was broken. Risk Management was notified by Supervisor on 02/16/2018. Risk Analyst spoke via telephone with patient #3's family member on 02/23/2018. Further interview revealed no further communication had occurred to date and there was no other documented verbal or written correspondence available.

NC 026