HospitalInspections.org

Based on document review and interview, the facility failed to follow their established Patient and Customer Complaint/Grievance policy for 8 of 13 (#1, # 2, # 3, # 4, # 6, # 7, #8, # 10) patient complaints reviewed. The facility failed to document thorough investigations, prompt resolutions, and that the complainants were informed of results.


Findings include:



Patient # 1

Review of the document titled "Patient/Family Concern" dated 2/4/19 at 9:05 a.m. revealed a concern on behalf of patient # 1's family was received by phone from a home health nurse. The home health nurse was reporting concerns with patient #1's discharge. The following was reported: patient #1's "family very (sic) upset stating she was supposed to be discharged to SNF or nsg (sic) home but instead van from rehab took her home. When family called (the facility) they were told van could not transfer until Monday. States family has tried to care for her all weekend and she cannot even feed herself. Family extremely upset. Pt's case mgt (sic) note on 2/2 indicates home (with) home health." The document was signed 2/4/19 at 9:15 a.m. by staff # 7.

A review of the section titled "Results of Investigation," revealed a statement from staff # 8 as follows: "On 2/1 I spoke (with) grandson (Proper Name) numerous times to discuss either admit back to (the facility), to ER if change in status, or SNF placement on Monday. Sent referrals to (2) SNF facilities on Saturday. Spoke c (sic) grandson to check on pt 2/2 at 1130. He states all was ok during the night. Discussed options again. Attempted to contact grandson (Proper Name), am 2/4. Left voicemail. Spoke with (Proper Name) (case manager) - State SNF was never discuss."

Further review of the documentation revealed staff # 7 documented "I called and left a message (with) HH nurse that our case manager has been in touch c (sic) the grandson several times over the weekend to get patient #1 placed in nsg home ASAP."

There was no documentation found that staff ever spoke with the family or home health agency following the complaint, or that they were satisfied with the results.

Review of the patient's medical record revealed the patient was discharged from the facility on 2/1/19.

Review of the document titled "Patient/Family Concern" dated 2/7/19 at 10:15 a.m. revealed a complaint received by phone from a home health nurse reported the following: "HH nurse states family (grandson) (Proper Name) thought that patient was being discharged to SNF but was brought home. Contacted case manager and said he thought (facility name) was getting her in nursing home Saturday so told home health not to come. Sunday grandson called and said the rehab didn't come. So home health went to see patient. Grandson told home health he isn't sure why they would send any patients to (facility name)."

There was no documentation found to show the facility addressed this concern.



Patient # 2

Review of the document titled "Patient/Family Concern" dated 3/4/19 at 1:50 p.m., revealed a concern from a family member on behalf of patient # 2, by telephone, regarding food/diet and general care concerns. The following was reported: "Rec'd call from (Proper Name), pt's daughter. She c/o pt not being toileted q 2 (hours), diapers still being used at night, 0 thickened water at bedside and states last shower was given last week also concerned re: no bm x several days. I apologized and let (Proper Name) know I would investigate." This was signed by staff # 4 on 3/4/19 at 1:50 p.m.

A review of the section titled "Results of Investigation," revealed the following: "Pt rec'd muralax (sic) and biscodyl (sic) this morning. SLP orders 0 water to be left at bedside d/t extreme swallow difficulties. Pt is being toileted, but she demands, "get me up" just as soon as she sits on commode. Will follow up with night shift re: 'no diaper' request by family. This was signed by staff # 4 on 3/4/19 at 2:15 p.m.

There was no documentation found the complainant was ever contacted regarding the findings. There was no documentation regarding any resolution and if the complainant was satisfied with any resolution.



Patient # 3

Review of the document titled "Patient/Family Concern" dated 4/4/19 at 11:00 a.m. revealed a concern from patient # 3, the spouse and the home health nurse, was received by phone regarding discharge and general care. The following was reported: "Patient called 4/3/19 1100 stated 'I have had a terrible night suffering c (sic) no oxygen. 'Spoke c (sic) (Proper Name) RT she had done overnight pulse ox (sic) on patient and qualified him for O2 she ordered the O2 from (Proper Name Company). I called (Proper Name) they stated 'its on its way soon.' Called spouse back to her (Proper Name) had been called and would be bringing and she stated 'he had a bad night.' 'Home Health is on the way too.' I told spouse to call (illegible) office if she felt he needed to be seen sooner than appointment. She agreed. 4/4/19 (Proper Name) home health nurse c (sic) (Proper Name) called stated patient had 26 lb weight gain while here at (facility) per the nurse of fluid (sic). Home health nurse had to call about O2 also. Patient had gone to (hospital) this AM. Patient was CHF diagnosis here."

A review of the section titled "Results of Investigation," revealed a statement from staff # 7 as follows: "4/5 attempted to call wife no answer. Visited c (sic) CM (Proper Name) regarding incident. Researched chart, documented weights. Visited with RT (Proper Name) did overnight pulse ox (sic) study and also ordered oxygen night of 4/2, pt dc date. Attempted to contact (Proper Name), mgr of (Proper Name Company); she is out until Monday. 4/11 2:30 p: A review of the section titled "Results of Investigation," revealed a statement from staff # 7 as follows: Again attempted to phone (patient # 3 spouse) (as husband in hospital), no answer, no answering machine to leave voice message. Issue of possible error in weight documentation will be discussed c (sic) nursing CNO." This was signed by staff # 7 on 4/11/19 at 2:40 p.m.

Further review revealed no documentation of a resolution or that the complainants were ever notified regarding the results of the investigation, however it was documented resolved by staff # 7 on 4/11/19.



Patient # 4

Review of the document titled "Patient/Family Concern" dated 4/15/19 at 11:24 a.m. revealed a concern from a family member of patient # 4 was received by phone regarding discharge and general care. The following was reported: "During routine call back (Proper Name) (wife) said patient # 4 is back in the hospital because 'You gave him pneumonia." D/C from (facility) 4/9/19; Admit to (hospital) 4/11-4/12 with bacterial pneumonia and acute dyspnea; Spoke with (Proper Name) as (hospital) medical records," signed 4/15/19 at 11:30 a.m.

A review of the section titled "Results of Investigation," revealed a statement from staff # 7 as follows: "1. Researched chart. CXR done week before d/c PICC line placement does not indicate pneumonia. Doctor does not document any concerns of pneumonia. Pt was somewhat SOB but considered WNL for him. 2. Phoned wife. She is 'positive' he got pneumonia while at rehab. Says he is home from hospital now, still on antibiotics but he is off O2 and not SOB. Shared chart findings but she is adamant pneumonia occurred here. Apologized and told her I'm thankful he is doing better," signed 4/15/19 at 1:00 p.m., by staff # 7.

There was no documentation found regarding resolution of this continued concern or complainant response to findings after 04/15/2019.



Patient # 6

Review of the document titled "Patient/Family Concern" dated 5/9/19 at 7:15 p.m. revealed a concern from patient # 6 was received verbally regarding professional/respect concerns. The following was reported: "(Staff # 9) came into her room to get vitals. As she was putting cuff on pts arm pt asked for help as she was hurting and needed to roll. (Staff # 9) ignored the pt and continued getting her vitals. Pt once again asked for help. (Staff # 9) placed the thermometer in pt mouth. After getting the vitals, (staff # 9) rolled pt, but pt state it hurt to please get help to turn her at that time she said that (staff # 9) turned and left the room. Stated that (staff # 9) hardly spoke to her and poor bedside manner."

A review of the section titled "Results of Investigation," revealed a statement from staff # 7 as follows: "Employee was counseled. Discussed CPR and improvement goals," signed 5/23/19 at 6:36 p.m. by staff # 4. Further review revealed staff # 9 was no longer assigned to care for the patient by staff # 3.

There was no documentation found of the patient being notified of the resolution or if patient # 6 was satisfied with the outcome.



Patient # 7

Review of the document titled "Patient/Family Concern" dated 5/27/19 at 9:00 a.m. revealed a concern from patient # 7, a family member, and patient # 7's physician was received verbally regarding a "nursing issue." The following was reported: "Pt and husband state she has infection in her incision. They stated she has not had a shower but once (yesterday) Informed charge RN. She stated pt has tissue infection and was started on Rocephin Cultured 5/25/19. Dr. Moody sent over orders last week for patient to have Daily showers (Proper Name) is aware."

There was no documentation found the facility investigated the concern or ever responded to the complainant regarding a resolution.




Patient #8

Review of the document titled "Patient/Family Concern" dated 07/08/19 at 8:45 a.m., revealed a concern from a family member of patient #8 was received by telephone regarding general care issues. The following was reported: "That patient's room was 65 degrees and very cold; That during the day after several attempt no one would put the pt in her bed, so she had to take herself to the dining room; O2 off for several of hours during the day; Pt states she sat on toilet for extended time waiting on help. Cannot reach call light."

Review of the section titled "Results of Investigation" revealed staff # 3 documented the following; "Attached is call light report. Will discuss c (sic) staff in quality huddle and follow up with family. Discussed c (sic) nurse tech regarding call light etc. Spoke with daughter about issues," signed by staff # 3 7/9/19 at 8:00 a.m.

There was no documentation found the complaint of the patient's oxygen being off for several hours during the day, the temperature of the patient's room and the complaint the patient had to wheel herself to the dining room because no one would assist her back to bed, were ever investigated by the facility or that a resolution was presented to the complainant.



Patient # 10

Review of the document titled "Patient/Family Concern" dated 9/10/19 at 8:00 a.m. revealed a concern, from a facility staff member was received by phone regarding discharge of patient # 10. The following was reported: "Family was not at home when van arrived with pt. Another family member came to residence and picked up pt. Van driver returned a few hours later to deliver equipment and found pt lying on the porch. Family states they were not able to help patient into house. (Proper Name) helped pt into home. The following day family called stated they sent him to (facility name) ER. Family states pt had temp 101.5 upon arrival."

A review of the section titled "Results of Investigation," revealed the following: "9/10 9:40 called pt's house left message asking them to call me. Also called dtr's phone, no answer mailbox full. 9/11/19 No response from messages left yesterday. CEO stated family was upset because pt was dc'd from rehab but d/c was necessary as pt. refused therapy. No further action required per CEO."

Further review of the documentation revealed two statements by staff members. An undated statement provided by staff # 10 noted she spoke with a family member regarding a concern that the patient required five people to transfer at home and had to be sent to the emergency room, and that patient # 10 also had a fever of 101.5. Staff # 10 stated she informed another staff member who would be following up. A statement provided by staff # 11 was an accounting of the incident when the driver dropped the patient off at home and returned with equipment and found the patient on the ground.

There was no documentation found that any further investigation was conducted or that the complainant was ever contacted either by phone or in writing.


During an interview on 11/13/2019 after 11:00 a.m., Staff #'s 2 and 3 confirmed the information
about the grievances.




A review of the document titled "Patient and Customer Complaint or Grievance policy" with effective date of 07/10/2019, and last review date of 07/10/2019, revealed:

"Patient Complaints

Not all complaints rise to the level of a grievance. For example, if the issue meets all the following criteria, it is considered a complaint and does not require a written response.

1. Issue is of minor nature (i.e. change in bedding, housekeeping issues, room temperature, serving preferred food and beverages, noise level) AND

2. Issue is not a recurring issue AND

3. Issue can be resolved by staff present ("staff present" includes any hospital staff, i.e. nursing/clinical leadership, administration, patient advocate, etc., present at the time of the complaint or who can quickly be at the patient's location to resolve the complaint) AND

4. The patient is satisfied with the actions taken. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf ... ... ...

Patient Grievances

Not all complaints will meet the criteria of a grievance. Complaints meeting any of the criteria below are considered grievances and require a written response ... ....

2. Complaints regarding the patient's care or with an allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more CoP's, or other CMS requirements.

3. 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 actions for resolution ... ... ... .....

Patient Grievance- Action to be taken: The hospital must review, investigate and resolve each patient's grievance within a reasonable time frame and provide a written response. Grievances involving situations that potentially endanger the patient such neglect or abuse should be reviewed immediately. Upon notification, the patient will be immediately removed from any situation that may endanger the patient. While requirements for written response are listed below. The company strongly encourages initiating and maintaining personal contact throughout the investigation.

1. Staff will document all communications with the patient and/or patient's representative. The staff documentation will include the date, time, and a summary of the conversation.
2. Hospital CEO or designee must initiate an investigation in coordination with hospital Risk Management if needed and determine the necessity for completing an Event Report (RM-600) and/or a Root Cause Analysis (as defined in RM-691).
3. A written communication must be sent to the patient (or patient's legal representative), even if other methods of communication are used (such as a family meeting). On average, the written response should be completed within 7 calendar days of receipt of grievances. When a patient communicates a grievance to the hospital via email or requests a response via email the hospital must provide the patient with:

Findings and determination regarding the grievance in a language and manner the patient and/or family understands;
written notice of its decision and the name of the hospital contact person; the results of the grievance process and the date of completion;

a statement that provides the patient/family with information on how to contact the hospital CEO or designated contact for any issues they feel remain unresolved.

4. If hospital CEO or designee determines the investigation is not or will not be completed within 7 calendar days, he/she must provide patient/family with verbal or written progress report.

Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days. The initial contact must include:

Statement acknowledging receipt of the grievance;

Specific time frame when the patient/legal representative can expect conclusion/resolution to their expressed grievance

5. Hospital Human Resources will follow up with departmental supervisor for action taken regarding employee issues if indicated.

6. The hospital should make sure that it is responding to the substance of each grievance, while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.

7. All grievances must be recorded in the hospital grievance log. The entry into the log must include:
date received
nature of grievance
who responded
action (s) taken
date of final written response (and initial response, if necessary)

PROCEDURE INSTRUCTIONS
The procedure must describe the hospital-specific structure for the program and any state-specific reporting requirements. This would include if the Governing Body has delegated, in writing, their responsibility to review and resolve grievances to a grievance committee. For example: The hospital's governing body must approve and be responsible for the effective operation of the complaint/grievance process. Under the designated authority of the governing body, the hospital's Administrative Team (CEO, CNO, DTO, DQR, DCM) is assigned the responsibility to review and resolve grievances through the process defined below."

The hospital failed to follow its own policy with regards to handling grievances as complaints.