HospitalInspections.org

Based on document review and interview, the facility failed to ensure a grievance was investigated, the complainant was notified of a plan of action and provision of a written response to a grievance for 1 of 6 incidents reviewed. (Family member #1)

Findings include;

1. Facility policy titled "Complaints and Grievances" last reviewed/revised 2/2018 indicated the following: "...POLICY: The mission ...is to promote quality, value and optimal outcomes of all services provided to our patients. All complaints and grievances are reported. ...A grievance is a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. Any complaint not resolved promptly by staff present is to be considered a grievance. ...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postpones 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 for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. ...COMPLIANCE GUIDELINES: 1. Grievances (complaints) may be verbal or written. 2. Grievances may be brought by an individual or through patient and family groups. 3. A grievance is acknowledged, investigated, and the complainant apprised of progress toward resolution. ...PROCEDURE:
...3. Record the date, resident/family name, and issues or concern on the center complaints/grievance log. 4. Assign the appropriate Department Head to investigate. 5. Investigate to validate the complaint/grievance. 6. Notify patient and/or family/responsible party of progress. Typically, a response time of seven days is appropriate; most grievances should be resolved within that amount of time. 7. If an investigation cannot be completed or a grievance cannot be resolved within seven days, the patient or the patient's representative should be informed that the process is ongoing and that he or she will receive a written response within a specified time period according to organizational policy. 8. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion. 9. When the grievance is resolved ...Written responses should be sent even if appropriate staff members meet with the patient and family members and resolve the grievance during the discussion. ...11. ...The hospital must attempt to resolve all grievances as soon as possible. 12. Determine resolution. ...14. Record the date resolved and resolution on the form. ...17. Conduct on-going follow-up to validate resolution is maintained and the patient and family member/responsible parties are satisfied with the resolution ...."

2. Facility policy titled "Patient Rights and Responsibilities" last reviewed/revised 9/25/18 indicated the following: "...26. ...The grievance committee will review each grievance and provide you with a response within 7 days. The written response will contain the name of a person to contact at the hospital, the steps take to investigate the grievance, the results of the grievance process, and the date of the completion of the grievance process. Concerns related to quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Control Peer Review Organization (PRO) ...."

3. Facility policy titled "Plan for Provision of Care" last reviewed/revised 12/2016 indicated the following: " ...Quality Management Department: ...Although the Quality Management department does not provide direct patient care, the primary goal of the department is to ensure the safe, appropriate, effective, and responsible care of all patients. ...The DQM [Director of Quality and Risk Management] serves as the Risk Manager and assists to ensure the safety of staff, visitors, and patients by investigating and disseminating related information on all employee/patient/visitor incidents within the facility. The DQM is responsible for ...participating in investigation and evaluation of safety and risk hazards ...."

4. A review of an incident documentation from A#1 (Director of Quality) dated 9/14/18 at 6:30 p.m., it indicated communication with FM#1 (family member of patient #11) and FM#2 (family member of patient #11) related to patient #11 began on 9/12/18, after he/she was informed during a flash morning meeting. The communication documentation indicated on 9/12/18 that FM#1 had many complaints about the care of patient #11, which included but was no limited to patient had a deep vein thrombosis that staff kept touching and that it hurt and was making the patient restless and start thrashing. FM#1 did not want the patient restrained and preferred him/her and FM#2 sit by his/her side and ensure the patient would not pull at his/her trach site. FM#1 had a concern that the patient would be over-sedated and could not participate in therapy and concern related to the physician ordering Haldol and the risks of using it. On 9/14/18 at 10:15 a.m., FM#1 brought additional concerns related to patient #11's care, which included but were not limited to patient #11 not having a working call light, his/her bed was wet something wrong with the Foley, took 1.5 hours to get patient #11's bed changed and his/her pulse ox came off, causing a loud beeping and it took staff 15 minutes to respond.. The documentation addressed the medication, restraint concerns and included multidisciplinary team approach with the physicians, pharmacist, quality director, FM#1 and FM#2. The incident documentation lacked documentation addressing/investigating the additional patient care concerns for patient #11. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response within 7 days of receiving the grievance.

5. A review of communication documentation provided by A#4 (Nurse Manager) on 9/27/18 at 4:06 p.m., indicated an email from FM#1 to him/her on 9/17/18 at 1:12 p.m. of FM#1's specific concerns related to
patient #11's care and that he/she wanted to touch base with A#4. The email contained additional concerns not mentioned in the incident communication completed by A#1 on 9/14/18, along with previous patient care concerns The additional concerns included but were not limited to: a) Staff moving patient #11 in bed and in the process popped the balloon cuff in his/her trach on 9/10/18. b) FM#1 requested a meeting with the charge nurse that evening, so a report could be taken of the event but the information was not even passed on to day shift and a report was not completed. c) A#1 not addressing the additional patient care concerns/issues, which included but was not limited to call light not working for 9 days and no response to alarms. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response to the grievance within 7 days of receiving the grievance.

6. An interview on 9/27/18 at 4:33 p.m. with A#8 (Vice President of Quality and Risk Management), he/she indicated the complaint related to patient #11 would be considered a grievance.

7. An interview on 9/27/18 at 4:48 p.m. with A#8, he/she indicated that if a complaint cannot be resolved within 24 hours then it would be moved into the grievance process and put it into incident reporting and sent to the DQM (Director of Quality Management). A#8 indicated that the grievance is viewable to those assigned it by the DQM. He/she indicated the investigation and follow-up of the grievance would occur and depending on the allegations would include physicians and department heads. He/she indicated they would also bring in any staff that was assigned to that patient, have a conversation with them and depending on what is shared would determine the next step of the grievance process. A#8 further indicated that the patient's medical record would be reviewed to see what was documented by the several disciplines.

8. An interview with FM#1 on 9/27/18 at 6:45 p.m. via telephone conversation, he/she indicated they cannot say the complaints/grievance was resolved. FM#1 indicated he/she had spoken with several people multiple times related to his/her concerns. The staff FM#1 had spoken with included A#6 - two times, A#1 -multiple times, A#4 via text, telephone, email combined a total of 4 times and 1 of those times was today, which was approximately an hour ago. FM#1 indicated that FM#2 has spoken to physicians and FM#1 has spoken with MS#2 (Internist) and he/she was going to give Haldol to the patient.