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Based on interview and record review the hospital failed to follow their policy "Patient Complaints/Grievances" when one of two sampled patients (Pt 19), grievance acknowledgment letter was not sent out in 7 days, an extension letter was not sent out after the initial 7 days, and the response to the grievance was sent out 36 days after receipt of the grievance.

This failure resulted in Pt 19 not receiving a timely response to their grievance.

Findings:

During a concurrent interview and document review on 12/4/25 at 11:06 a.m. with the Administrative Services Manager (ASM), Director of Clinical Quality Improvement (QD), and the Patient Safety Officer (PSO), the hospital's "Grievance & Complaint Log," undated and grievance process was reviewed. The QD stated patients could file grievances in a couple of different ways from calling a phone number that is available all the time, they can email them, mail, fax, the Press Ganey Survey (a standardized patient experience questionnaire used by thousands of United States healthcare organizations to measure satisfaction with care). The QD stated they also do leadership rounding where we could get the grievances from staff and patients directly. The ASM stated, "When we receive a grievance, we review it and determine which department Director and Manager they should send it to. The ASM stated the expectation is for them to start their investigation while we send out a letter to the patient or patients' representative to let them know we received their grievance and will be looking into the issues." The ASM stated this letter was usually sent out within the first 7 days of receipt of the grievance and if the investigation took longer than 7 days then we would send out another letter explaining more time was needed. The ASM stated the goal was to have the grievances resolved within 30 days of receipt of the grievance. The ASM stated she/he was surprised when the Grievance & Complaint log was reviewed and grievance number 14 for Pt 19 was received on 9/9/25 and the resolution letter was sent on 10/15/25 (36 days after receipt of the grievance). The QD stated grievance 14 was emailed to both her and the ASM and they were not sure why it took so long for them to send over the grievance to the Director and Manager of the Emergency Department (ED). The QD stated on 10/2/25, grievance 14 was sent to the Director and Manager of the ED. The ASM stated it should not have taken 36 days for the resolution letter to go out for Pt 19.

During an interview on 12/5/25 at 10:36 a.m. with the Chief Nursing Officer (CNO), the CNO stated she met weekly with the grievance committee to review the status of current grievances. The CNO stated her expectation was staff should follow the Grievance policy.

During a review of the hospitals policy and procedure (P&P) titled, "Patient Complaints/Grievances," dated 8/28/25, the P&P indicated, " ... II. PURPOSE: The Hospital places a high value on delivering excellent service that is responsive to individual needs. This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. III ... B. "Grievance" an oral or written Complaint that is not immediately resolved at the time of the Complaint by staff present. A Grievance may be made by the patient's representative regarding, but not limited to the patient's care, abuse or neglect ... A written Complaint is always considered a Grievance and may be submitted by fax or email. Whenever the patient or patient's representative requests that the Complaint be handled as a formal Complaint or Grievance, or when the patient requests a response from the hospital, then the Complaint is a Grievance ... IV ... The patient shall have the ability to file a Complaint or Grievance as part of the patient rights process and in compliance with the Medicare CoP ... V. ... C. Patient Grievance 1. Whether a patient/family Grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution ... 3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response in 7 days ... If the resolution of the grievance is determined to take longer than 7 days, the Grievance Committee or designee will send 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 shall elapse before a response is sent to the patient. If a grievance is made by a patient's attorney, hospital operations counsel or litigation claims person before any written response to the grievance, including a deferral letter or final letter is given ... 4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and patient's legal representative understands within 30 days. The hospital may use additional tools to resolve the grievance such as a meeting with the patient or family ... E. Responsible Person The DCQI (Director of Clinical Quality Improvement) or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non-compliance with this policy are reported to the Chief Nursing Officer (CNO) ..."

Based on interview and record review the hospital failed to follow their policy "Patient Complaints/Grievances" when two of two sampled patients (Pt 17 and Pt 19), grievance letters were not sent to either of the patients because the grievances were submitted by their insurance companies.

This failure resulted in both Pt 17 and Pt 19 not receiving answers to their grievances.

Findings:

During a review of the hospital's "Grievance & Complaint Log last 6 months," undated, the log indicated, " ... 13 Date Received 9/5/25 Tracking # (number sign) 3020 [patients] Name/Complainant Name [insurance company name] on behalf of [Pt 17's name] ... Grievance Description ... member [Pt 17] states she was admitted on 8/18/25 and left after the ER physician was yelling at her for asking a couple of questions. Member states the nurses and member's friend tried standing up for her, but the physician would not change his attitude, so she left. Method of Receipt Written ... Department Involved ED ... Date Final Resolution Letter Sent 9/12/2025 ... 14 Date Received 9/9/2025 Tracking # 3021 Pt's Name/Complainant Name [name of insurance company] on behalf of [Pt 19] ... Grievance Description DOS (date of service): 8/29/25. Per father [for Pt 19], pt needed an MRI (Magnetic Resonance Imaging- uses strong magnets, radio waves, and a computer to create detailed images of soft tissues like the brain, spinal cord, muscles, ligaments, and organs) for a loose knee. [Doctor] was rude and didn't help pt, did not do any physical tests, x-ray (imaging test using electromagnetic radiation to create pictures of the inside of the body) done but did not answer questions and didn't diagnose pt. Was pt advised to see his PCP or a specialist? Method of Receipt Written ... Department Involved ED ... Date Final Resolution Letter Sent 10/15/2025 ... # of days from Grievance Receipt to Resolution Letter 36 ..."

During an interview on 12/3/25 at 5:09 p.m. with Pt 17, Pt 17 stated she filed a complaint with her insurance company for her visit on 8/18/25 to this hospital. Pt 17 stated the hospital never reached out to her and she had not received any letter from the hospital related to her complaint.

During a concurrent interview and document review on 12/4/25 at 11:06 a.m. with the Administrative Services Manager (ASM), the Director of Clinical Quality Improvement (QD), and the Patient Safety Officer (PSO), the hospitals "Grievance & Complaint Log last 6 months," undated was reviewed. The QD stated Pt 17 and Pt 19's grievances came from their insurance companies and neither of the patients were contacted about these grievances and the resolution letters went to the insurance companies and not the patients. The QD stated Joint Commission (accreditation is the objective evaluation process that can help health care organizations measure, assess, and improve performance in order to help healthcare organizations fulfill their mission to provide safe, high-quality care) was just here doing a survey and recommended we send resolution letters to the patients involved in the grievances, but they had not.

During an interview on 12/5/25 at 10:36 a.m. with the Chief Nursing Officer (CNO), the CNO stated she met weekly with the grievance committee to review the status of current grievances. The CNO stated her expectation was staff should follow the Grievance policy. The CNO stated, "Unless an insurance company asked us not to send a letter to the patient, the hospital should send the resolution letter to the patient, so the patients knew the hospital addressed the issues the patients reported.

During a review of the hospitals policy titled, "Patient Complaints/Grievances," dated 8/28/25, the policy indicated, " ... II. PURPOSE: The Hospital places a high value on delivering excellent service that is responsive to individual needs. This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. III ... B. "Grievance" an oral or written Complaint that is not immediately resolved at the time of the Complaint by staff present. A Grievance may be made by the patient's representative regarding, but not limited to the patient's care, abuse or neglect ... A written Complaint is always considered a Grievance and may be submitted by fax or email. Whenever the patient or patient's representative requests that the Complaint be handled as a formal Complaint or Grievance, or when the patient requests a response from the hospital, then the Complaint is a Grievance ... IV ... The patient shall have the ability to file a Complaint or Grievance as part of the patient rights process and in compliance with the Medicare CoP ... V. ... C. Patient Grievance 1. Whether a patient/family Grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution ... 3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response in 7 days ... If the resolution of the grievance is determined to take longer than 7 days, the Grievance Committee or designee will send 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 shall elapse before a response is sent to the patient. If a grievance is made by a patient's attorney, hospital operations counsel or litigation claims person before any written response to the grievance, including a deferral letter or final letter is given ... 4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and patient's legal representative understands within 30 days. The hospital may use additional tools to resolve the grievance such as a meeting with the patient or family ... E. Responsible Person The DCQI (Director of Clinical Quality Improvement) or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non-compliance with this policy are reported to the Chief Nursing Officer (CNO) ..."