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SINAI-GRACE HOSPITAL 6071 W OUTER DRIVE DETROIT, MI 48235 Jan. 12, 2021
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to follow their procedure for complaints and grievances investigation and resolution for one (#1) of three patients reviewed for complaints and grievances out of a total sample of 11, resulting in the potential for unresolved grievances and the denial of patient rights.

A review of the medical record for patient #1 was conducted on 1/11/2021 at 1215 and revealed the patient (MDS) dated [DATE] at 2319 for a complaint of a mental health crisis. The patient was discharged on [DATE] at 0128.

On 1/11/2021 at 1515 a review of the facility's Complaints/Grievance logs were reviewed with the Director of Patient and Guest Relations (Staff I) and revealed the patient of concern #1 had filed a grievance on 11/25/2020.

A review of the correspondence with the complainant and Staff I was reviewed and revealed the following:
On 11/25/2020 (lst letter sent out to the complainant): "...Your concerns are being shared with the appropriate leaders for review and investigation. You will receive a written follow-up letter at the completion of this investigation, within 30 days...If I may be of further assistance to you, feel free to call me at (office number for Staff I)..."

On 1/11/2021 at 1530, during an interview Staff I was asked to prove evidence that documented an investigation had been conducted, and evidence that a follow-up letter had been mailed out to the complainant that noted the completion of an investigation and the outcome of their findings. At that time, Staff I said I don't have anything. She said I contacted the Interim Emergency Department (ED) Director (Staff D) and the (ED) Nurse Manager (Staff E) on 11/25/2020 and they never responded.

Staff I further stated, "I received another grievance from the complainant (#1) on 12/29/2020 regarding the same concerns." Staff I stated, "I emailed the letter to the same people, (Staff D and Staff E) and they have yet to respond.

On 1/12/2021 at 1445, during an interview the Chief Nursing Officer confirmed that Staff D and Staff E were responsible for investigation and follow-up of the patient's grievances.

Review of the facility's "Patient & Family Complaints and Grievances" policy dated September 1, 2020 documented:
C. Patient Grievance:
1. Complaints meeting the definition of a grievance are forwarded to the manager/director of the affected or involved department for investigation and resolution.

2. If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director forwards a copy of the Patient and Family Complaint/Grievance report to the Director, Clinical Quality Improvement (DCQI) or the Patient Safety Officer enacts the bill hold process and completes an event report (see Clinical Safety Policy CO-2.008) Event Reporting).

3. The seriousness of the grievance drives the response times.
-Grievances should be resolved and the patient notified of the response in 7 days. (Note: allegations of abuse or neglect are managed in accordance with time frame of policy RCC-4.60.

-If the resolution of the grievance is determined to take longer than seven days, the Grievance committee or designee sends a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a "Deferral letter").

-No more than seven days elapses before a response is sent to the patient.

4. Each issue is defined as a grievance is followed up with a written notice of decision in a manner and language that the patient and the patient's legal representative understands within 30 days from Patient/Guest Relations. The hospital may use additional tools to resolve the grievance such as meeting with the patient or family. The written response contains the following minimum elements:
Date of receipt of grievance
Name of the hospital contact person for patient follow-up if needed
Steps taken to investigate, and results and dates completed
Date of investigation completion.

However, this was not done.