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Based on a record review and staff interviews, the hospital failed to ensure the prompt resolution of complaints and grievances for two of the six sampled patients (Patients #1 and 2). The hospital staff failed to ensure:


A. a grievance involving patient care was properly identified as a complaint/grievance, logged in the complaint/grievance log, and thoroughly investigated and resolved for patients listed on the "Complaint Report".

B. the grievances regarding patient mistreatment and care complaints for two patients (Patient # 1 and 2) out of six were thoroughly investigated within the timeframe in accordance with the facility policy titled "Patient Complaint and Grievance Process."

Findings include:

A. There were 22 entries on the "Complaint Report" from June through August of 2025. Only 2 were listed as grievances, and the other 20 entries were listed as complaints.

A review of the complaints revealed that only 2 were addressed with a staff member present and resolved. The other complaints should have been categorized as grievances according to the facility's policy.

Patient # 1

A review of the hospital's "Complaint Report," dated 06/10/2025, revealed that Patient #1 was in the emergency room on 11/27/2024, having fallen out of his wheelchair. EMS told him his leg looked broken. The patient was assessed in the emergency department and discharged. The patient left the emergency department and went to another local hospital emergency room and diagnosed with a broken leg. The patient spent several months in the rehab unit.

A letter was sent within the 7-day timeline. There was documentation of the investigation, but no 30-day to 45-day follow-up. The next date was a resolution date of 8/1/2025 with no documentation of the outcome.

Patient #2

A review of the hospital's "Complaint Report," dated 06/12/2025, revealed that Patient #2 was in the emergency room on 06/09/2025. The patient was there due to vomiting, diarrhea, dizziness, and headache. The complaint was from the spouse, who stated she did not want medication administered to her partner. Additionally, the spouse complained that the physician was rude. A review of the Complaint intake was dated 06/11/20258.

During an interview on 09/05/2025 at 9:30 AM, Staff #11 confirmed there was no documentation of the allegation being addressed. This complaint was categorized as a complaint and should have been a grievance. The resolution date was 7/25/2025. This complaint was not handled at the time the incident happened.

A review of a facility's policy titled "Patient Complaint and Grievance Process" dated 12/21 revealed the following:

"Complaint -A verbal concern issued on behalf of a patient or patient's representative that can be resolved at the time by staff present.

Grievance -A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the Complaint is not resolved at the time of the Complaint by the staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing Complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489.

* "Staff Present" includes any hospital staff present at the time of the Complaint or who can quickly be at the patient's location (i.e. Nursing, Administration, Nursing Supervisors etc .. ) to resolve the patient's Complaint.

* If a verbal patient care Complaint cannot be resolved at the time of the Complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolutions, then the Complaint is a Grievance for the purpose of these requirements.

* A billing issue is not usually considered a Grievance unless it contains elements concerning quality of care or service issues or is Medicare Beneficiary billing Complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489.

Billing issues that do not meet the definitions of a Grievance may be referred to the department responsible for billing.
* A written Complaint is always considered a Grievance, whether from an inpatient, outpatient, releases/discharged patient or a patient's representative regarding the patient care provided, abuse, neglect, or the hospital's compliance with CMS Conditions of Participation (CoPs ). For purposes of this requirement an email or fax is considered "written."

* Information obtained from patient satisfaction surveys usually does not meet the definition of a Grievance. However, must be managed as a Grievance if a patient or patient's representative:
* Writes or attaches a written Complaint on the survey and request resolution or
* Writes or attaches a Complaint to a survey, does not request resolution, but the event would typically be treated as a Grievance by the hospital
* Patient Complaints that are considered Grievances also include telephone, verbal or written Complaints regarding patient care, allegations of abuse, neglect, patient harm or hospital compliance with CMS requirements
*Post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a Grievance
*Whenever the patient or the patient's representative requests that his/her complaint be handled as a formal Complaint or Grievance or when the patient or patient's representative requests a response from the hospital, then the Complaint is a Grievance and all the requirements apply.

d. The Department Director/Manager under the direction of the Grievance Committee responds to the Grievance with written notice to the patient or their representative within seven (7) calendar days of receipt of the Grievance. The notice is provided in a language and manner the patient or patient's representative understands and includes:
i. The name of the hospital contact person
ii. The steps taken on behalf of the patient or patient's representative to
investigate the Grievance;
iii. The results of the Grievance process; and
iv. The date of completion

e. If the Grievance is not able to be resolved within seven(?) calendar days, a written acknowledgment shall inform the patient or the patient's representative that the hospital is still working to resolve the Grievance and that the hospital will follow up with a written response within 30 calendar days or within 45 days if special circumstances require an extension." Etc.

During an interview on 09/05/2025 at 10:00 AM, Staff #1 confirmed that the timeframes were not met according to the hospital policy and that the complaints should have been categorized as grievances under the Hospital policy "Patient Complaint and Grievance Process."

Based on record review and staff interview, the hospital's staff failed to ensure a properly executed informed consent was completed in 2 (# 6 and # 20) of 20 patient medical records. Also, the hospital staff failed to follow the "Informed Consent" policy.

A review of medical records was conducted with Staff #1 on 09/04/2025 at 3:30 PM.

Findings include:

Patient # 6

Patient #6 arrived at the emergency room on 07/02/2025 with complaints of weakness. The patient was brought by ambulance from an assisted living center. According to the nurses' and physicians' notes, the patient was alert and oriented. The patient was not in acute distress and was discharged back to the assisted living where he resides.

A review of the consent for the emergency visit on 07/02/2025 showed that the patient's signature was left blank, and it was documented as due to weakness.


Patient #6 arrived at the emergency room on 08/29/2025 with complaints of nausea and vomiting. The patient was brought by ambulance from home. According to the nurses' and physicians' notes, the patient was alert and oriented. The patient was not in acute distress and was discharged back to the assisted living where he resides.


A review of the consent for the emergency room visits on 08/29/2025 showed that the patient's signature was left blank. The consent showed that the patient was unable to sign due to weakness.


Patient # 20

Patient # 20, age 39-year-old, came to the Emergency Room on 08/08/2025. Patient complains of not being able to speak for 2 days and having trouble walking for one day. Hypertensive in triage. Patient is eating normally, per the friend who is with him. Patient nods and shakes his head to answer questions. Patient denies abdominal pain or vomiting. The assessment by the nurse and physician showed no reason the patient could not sign.

A review of the consent for the emergency visit on 08/08/2025 showed that the patient's signature was left blank. The consent showed that the patient was unable to sign due to the patient having a possible stroke/weakness/no family.



A review of the hospital's policy titled "Informed Consent" with a date of 12/2024 revealed the following:

"Policy:
This policy describes responsibilities and the authority for obtaining or giving consent to treatment. The parameters of consent are clearly stated and authorized for the protection of the patient, physician, staff, and hospital.

Definition: "Consent" or "informed consent" to treatment means the individual understands and agrees to any physical contact or other treatment. The concept of consent to treatment is of fundamental importance to the hospital-patient relationship.
Informed consent should be obtained from patients prior to treatment. The legal
relationship between the hospital and the patient is a contractual one. The patient has a
basic right to self-determination.
Consent may be either expressed or implied. If expressed, it may be either written or oral. Implied consent arises from the nature of the situation such as when a patient holds out an arm for a shot, but where the patient has made no affirmative statement of consent. While expressed consent is best evidenced by a signed consent form, the written form or
authorization is not the "consent", but merely evidence of the fact that the patient has made the decision to proceed with or refuse the anticipated procedure.

Informed Consent
Consent is only possible when the person consenting has enough information to understand the proposed treatment and the alternatives.
Informed consent requires that the patient is informed of the nature of the contemplated treatment, the potential risks, the prospects for success, the possibility of complications, the risks and benefits of available alternatives, and the results likely if the patient remains untreated. Extremely remote possibilities that might falsely or detrimentally alarm the patient need not be disclosed. In general, the patient's informed consent should be obtained before treatment is performed. An exception to this is an emergency situation (a condition which constitutes a substantial and immediate threat to the life or health of the patient so that delay to obtain consent would jeopardize the health of the patient (See "Emergency Procedures") or when the patient is incapable of consenting. The person authorized to consent for the patient shall be given the relevant information in these circumstances.


Written Consent
A properly signed consent form, obtained prior to treatment, is the most effective manner in which to provide a valid authorization for a medical procedure. The patient should sign a consent for medical treatment and disclosure form at the time of registration or admission to the hospital. A
"Disclosure and Consent for Medical and Surgical Procedures" should be obtained for the patient before any surgical or invasive medical procedures are undertaken or if special circumstances arise. The consent form is kept in the patient's medical record. The patient's signature should be provided freely and of his or her own accord and witnessed by at least one staff person.

Verbal Consent
A verbal consent may be obtained if the patient is competent but is unable to write. If the patient or legal representative is unable to sign the general consent for medical treatment, the reason should be indicated on the consent form, and if possible, signed by two (2) witnesses. For medical and surgical procedure consenting, the conversation should be noted in the patient's medical record, indicating the time and nature of the consent, and, if possible, the conversation should be witnessed by at least two (2) persons."


An interview was conducted with Staff #1 on 09/04/2025 at 3:45 PM, and confirmed that the hospital staff were not obtaining proper consent before performing treatment and care on patients at the hospital. Staff # 1 confirmed that the hospital staff were not following the hospital's Informed Consent policy in obtaining two signatures if a patient could not sign.