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|TERRE HAUTE REGIONAL HOSPITAL||3901 S SEVENTH ST TERRE HAUTE, IN 47802||June 19, 2019|
|VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES||Tag No: A0120|
|Based on document review and interview, the hospital failed to provide for prompt resolution of a discharge grievance for 1 patient (P5) in 1 facility and failed to follow their policy for follow-up to the grievance.
1. Review of hospital policy, PolicyStat ID: 05, titled Patient Grievance or Complaint Management, Last Revised 01/2019, indicated the following:
Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS (Centers for Medicare and Medicaid Services) Conditions of Participation (CoP), or...
A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further actions for resolution.
Grievance Resolution Process:
Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or representative with seven (7) days of receipt of the grievance...
Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve and that the facility will follow-up with a written response within 21 days.
Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving...
A grievance is considered resolved when the patient and/or representative is satisfied with the actions taken on their behalf...However, the organization must maintain documented evidence of compliance with all regulatory requirements.
2. Review of the hospital's "Complaint Log 2019", indicated that on 5/31/19, guardian, G1, of patient P5 voiced complaints/grievances about the way the patient was discharged without his/her permission. The log indicated the "Resolution" as: "apologized for his/her experience; will share for peer review at staffing level and physician consideration". "Satisfied with outcome? Yes No NFC (No further contact)": "NFC-not happy during call". "Response within 7 days (for Grievance)": NA. "Response within 21 days (for Grievance)": NA. "Complaint or Grievance": "complaint - re: discharge process/communication".
3. Between approximately 5:00 p.m. and 6:00 p.m., A3, Quality Manager, indicated that the hospital complaint/grievances person (currently out on leave) had received a call from P5's guardian, G1 (stated to have been received on 6/10/19) with complaints of the guardian having felt threatened with a bill from the hospital and patient care needs and was not able to participate in the patient's discharge. A3 indicated that with the complaint/grievance only having came in on 6/10/19 and the staff member responsible for complaints/grievances being out on leave, no further follow-up action had yet been taken with the complainant. In further discussion, A3 verified that the "Complaint Log" indicated the "Date Complaint" was 5/31/19, the column for "Response within 7 days (for Grievance)" was marked NA (Not Applicable) as was the column for "Response within 21 days (for Grievance)". A3 indicated the hospital did not have documentation of a 7 day follow-up with the complainant or patient, nor had they sent a letter with an anticipated follow-up/conclusion date and contact information.