HospitalInspections.org

Based on hospital policy review, hospital document review, incident report review, and staff interview, it was determined the hospital failed to ensure a clear grievance process was established with appropriate definitions of complaints and grievances for 6 of 6 patients (#12, #13, #14, #15, #16, and #17) whose complaint incident reports were reviewed. Misidentification of grievances as complaints had the potential to result in missed investigations, resolutions and follow-up. Findings include:

A hospital document for new hire orientation, untitled and undated, regarding patient complaints and grievances, was reviewed. The document included:

- "Complaint - Patient issues that can be resolve [sic] promptly or within 24 hours"
- "Involve staff who are present at the time of the complaint"
- "Typically involve minor issues"

A hospital policy "Resolution of Patient Complaints/ Grievances," dated 9/2013, was reviewed. The policy included:

- "When the staff present are unable to resolve an issue: if a 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 actions for resolution, then the complaint is a grievance."
- "The Governing Body delegates the responsibility for the resolution of patient grievances to the administrator of the hospital. The administrator shall implement the processes outlined within the policy."

A second hospital policy "Incident Reporting," dated 9/2013, was reviewed. The policy included:

- "The staff that witnessed or discovered an unusual incident or occurrence (event) or received a patient or visitor complaint must complete the incident report PRIOR [sic] to the end of their shift."

The hospital failed to follow their policies and grievance process. Examples include:

1. A list of all incident reports filed between 1/01/16 and 10/24/16 were reviewed. Of 256 reports, 6 were documented as patient complaints however 6 of 6 complaints met the definition of a patient grievance. These 6 patient complaints were not captured as grievances, were not included on the hospital's grievance log, and did not include all required elements of grievance resolution. Examples include:

a. A hospital incident report for Patient #12, dated 4/22/16, was reviewed. The incident report was listed as "Other - Complaint - Medication" and was entered by Patient #12's Case Manager. The incident report included "Patient reports that she was supposed to get her pain medication at 6:00 am [sic] so she can participate comfortably in therapy and patient ended up getting her pain medication at 1:30 [sic] in the morning. Patient has not had a shower since 4/16/16. Patient's family reports that they see people laughing and joking at the nurses station but patient care is not being done [sic]."

The complaint was not resolved at the time it was made known, it involved patient care issues, and was referred for further investigation and resolution. The incident report documented a resolved date of 5/29/16.

b. A hospital incident report for Patient #13, dated 9/01/16, was reviewed. The incident report was listed as "Meal Times - Complaint" and was entered by the Patient #13's Case Manager. The incident report included "Pt c/o [complained of] that meals not being served on time and inconsistent through out day."

The complaint was not resolved at the time it was made known and was referred for further investigation and resolution. The incident report documented a resolved date of 9/09/16.

c. A hospital incident report for Patient #14, dated 5/02/16, was reviewed. The incident report was listed as "Patient Care Issues Complaint" and was entered by Patient #14's RN. The incident report included "Multiple complaints regarding Nursing care."

The complaint was not resolved at the time it was made known, it involved patient care issues, and was referred for further investigation and resolution. The incident report documented a resolved date of 5/06/16.

d. A hospital incident report for Patient #15, dated 7/15/16, was reviewed. The incident report was listed as "Complaint" and was entered by Patient #15's Case Manager. The incident report included multiple patient care issues involving comfort and medications.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 7/18/16.

e. A hospital incident report for Patient #16, dated 8/15/16, was reviewed. The incident report was listed as "Complaint" and was entered by Patient #16's Case Manager. The incident report included patient care issues and staff complaints.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 8/15/16.

f. A hospital incident report for Patient #17, dated 9/14/16, was reviewed. The incident report was listed as "Family Complaint" and was entered by Patient #17's Case Manager. The incident report included patient care issues and staff complaints.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 9/14/16.

The Director of Compliance and the Area Director of Compliance were interviewed on 10/26/16, beginning at 1:30 PM, and the incident report complaints were reviewed in their presence. They confirmed the incident report complaints should have been captured as patient grievances and resolved accordingly. Additionally, they confirmed the incident report complaints were not listed on the hospital grievance log.

The Hospital Administrator was interviewed on 10/27/16, beginning at 10:30 AM, and the incident report complaints were reviewed in his presence. The Hospital Administrator stated he was designated by the governing body with the responsibility for the grievance process at the hospital. He confirmed the incident report complaints should have been captured as patient grievances and resolved accordingly. Additionally, he confirmed the incident report complaints were not listed on the hospital grievance log.

The hospital failed to identify patient grievances.

2. Hospital staff were interviewed about their understanding of the complaint/grievance process and when to enter them in the incident reporting system. Staff members interviewed provided inconsistent answers and understanding of the hospital's complaint/grievance process and incident reporting process. Examples include:

a. The DON was interviewed on 10/26/16, beginning at 10:10 AM. She stated complaints are entered in the incident reporting system "if needed." She stated the Director of Compliance was involved if the complaint was complex and acknowledged not all complaints are being captured in the incident reporting system.

b. An RN was interviewed on 10/26/16, beginning at 10:40 AM. She stated she was not familiar with the hospital grievance policy, incident reporting policy, or grievance policy. The RN stated complaints are not always entered in the incident reporting system. She stated she would refer complaints she received to the DON for resolution. The RN stated it would be her responsibility to assist a patient in filing a grievance, but stated she did not know how.

c. An RN House Supervisor was interviewed on 10/26/16, beginning at 11:05 AM. He stated he would go to the DON for help in resolving complaints. The RN House Supervisor stated he was unsure how to assist a patient in filing a grievance. He stated complaints regarding patient care received via telephone were not entered into the incident reporting system and were not being tracked.

d. An OT was interviewed on 10/26/16, beginning at 3:50 PM. She stated she did not know the difference between a patient complaint and grievance. The OT stated she did not recall receiving complaint/grievance training. She stated she would refer all patient complaints to the patient's RN for entry in the incident reporting system and resolution. The OT stated she would not document complaint issues, but would follow-up with nursing regarding resolution.

e. A PT was interviewed on 10/26/16, beginning at 3:35 PM. He stated he did not know the difference between a patient complaint and grievance. The PT stated patient complaints should go to the proper discipline and up the chain of command. He stated he would not document patient complaints in the incident report system and remarked "I'm not the complaint department."

f. The Hospital Administrator was interviewed on 10/26/16, beginning at 3:45 PM. He stated all staff should enter all complaints in the incident reporting system.

g. A PCT was interviewed on 10/27/16, beginning at 8:45 AM. She stated complaints would only be entered in the incident reporting system if they required interventions and was unsure if all complaints should be entered. The PCT stated she would refer the complaints to the patient's RN for help.

The Area Director of Compliance was interviewed on 10/27/16, beginning at 10:10 AM. She confirmed the staff answers regarding complaints, grievances, and the grievance process were inconsistent, did not follow hospital policy, and could impact patients' rights.

The Hospital Administrator was interviewed again on 10/27/16, beginning at 10:30 AM. He confirmed the staff answers regarding complaints, grievances, and the grievance process were inconsistent, did not follow hospital policy, and could impact patients' rights.

The hospital failed to ensure staff understood and followed hospital policies and grievance process.

Based on hospital policy review, hospital document review, incident report review, and staff interview, it was determined the hospital failed to ensure the effective operation and oversight of the grievance process by the governing body appointed designee for 6 of 6 patients (#12, #13, #14, #15, #16, and #17) whose complaint incident reports were reviewed. This had the potential to interfere with the effective operation of a grievance process for all patients who received care in the hospital. Findings include:

A hospital document for new hire orientation, untitled and undated, regarding patient complaints and grievances, was reviewed. The document included:

- "Complaint - Patient issues that can be resolve [sic] promptly or within 24 hours"
- "Involve staff who are present at the time of the complaint"
- "Typically involve minor issues"

A hospital policy "Resolution of Patient Complaints/ Grievances," dated 9/2013, was reviewed. The policy included:

- "When the staff present are unable to resolve an issue: if a 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 actions for resolution, then the complaint is a grievance."
- "The Governing Body delegates the responsibility for the resolution of patient grievances to the administrator of the hospital. The administrator shall implement the processes outlined within the policy."

A second hospital policy "Incident Reporting," dated 9/2013, was reviewed. The policy included:

- "The staff that witnessed or discovered an unusual incident or occurrence (event) or received a patient or visitor complaint must complete the incident report PRIOR [sic] to the end of their shift."

The hospital failed to follow their policies and grievance process. Examples include:

1. A list of all incident reports filed between 1/01/16 and 10/24/16 were reviewed. Of 256 reports, 6 were documented as patient complaints; however 6 of 6 complaints met the definition of a patient grievance. These 6 patient complaints were not captured as grievances, were not included on the hospital's grievance log, and did not include all required elements of grievance resolution. Examples include:

a. A hospital incident report for Patient #12, dated 4/22/16, was reviewed. The incident report was listed as "Other - Complaint - Medication" and was entered by Patient #12's Case Manager. The incident report included "Patient reports that she was supposed to get her pain medication at 6:00 am [sic] so she can participate comfortably in therapy and patient ended up getting her pain medication at 1:30 [sic] in the morning. Patient has not had a shower since 4/16/16. Patient's family reports that they see people laughing and joking at the nurses station but patient care is not being done [sic]"

The complaint was not resolved at the time it was made known, it involved patient care issues, and was referred for further investigation and resolution. The incident report documented a resolved date of 5/29/16.

b. A hospital incident report for Patient #13, dated 9/01/16, was reviewed. The incident report was listed as "Meal Times - Complaint" and was entered by the Patient #13's Case Manager. The incident report included "Pt c/o [complained of] that meals not being served on time and inconsistent through out day."

The complaint was not resolved at the time it was made known and was referred for further investigation and resolution. The incident report documented a resolved date of 9/09/16.

c. A hospital incident report for Patient #14, dated 5/02/16, was reviewed. The incident report was listed as "Patient Care Issues Complaint" and was entered by Patient #14's RN. The incident report included "Multiple complaints regarding Nursing care."

The complaint was not resolved at the time it was made known, it involved patient care issues, and was referred for further investigation and resolution. The incident report documented a resolved date of 5/06/16.

d. A hospital incident report for Patient #15, dated 7/15/16, was reviewed. The incident report was listed as "Complaint" and was entered by the Patient #15's Case Manager. The incident report included multiple patient care issues involving comfort and medications.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 7/18/16.

e. A hospital incident report for Patient #16, dated 8/15/16, was reviewed. The incident report was listed as "Complaint" and was entered by Patient #16's Case Manager. The incident report included patient care issues and staff complaints.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 8/15/16.

f. A hospital incident report for Patient #17, dated 9/14/16, was reviewed. The incident report was listed as "Family Complaint" and was entered by Patient #17's Case Manager. The incident report included patient care issues and staff complaints.

The complaint involved patient care issues and was referred for further investigation and resolution. The incident report documented a resolved date of 9/14/16.

The Director of Compliance and the Area Director of Compliance were interviewed on 10/26/16, beginning at 1:30 PM, and the incident report complaints were reviewed in their presence. They confirmed the incident report complaints should have been captured as patient grievances and resolved accordingly. Additionally, they confirmed the incident report complaints were not listed on the hospital grievance log.

The Hospital Administrator was interviewed on 10/27/16, beginning at 10:30 AM, and the incident report complaints were reviewed in his presence. The Hospital Administrator stated he was designated by the governing body with the responsibility for the grievance process at the hospital. He confirmed the incident report complaints should have been captured as patient grievances and resolved accordingly. Additionally, he confirmed the incident report complaints were not listed on the hospital grievance log.

The hospital's governing body failed to ensure the effective operation of the grievance process.

2. Hospital staff were interviewed about their understanding of the complaint/grievance process and when to enter them in the incident reporting system. Staff members interviewed provided inconsistent answers and understanding of the hospital complaint/grievance process and incident reporting process. Examples include:

a. The DON was interviewed on 10/26/16, beginning at 10:10 AM. She stated complaints are entered in the incident reporting system "if needed." She stated the Director of Compliance was involved if the complaint was complex and acknowledged not all complaints are being captured in the incident reporting system.

b. An RN was interviewed on 10/26/16, beginning at 10:40 AM. She stated she was not familiar with the hospital grievance policy, incident reporting policy, or grievance policy. The RN stated complaints are not always entered in the incident reporting system. She stated she would refer complaints she received to the DON for resolution. The RN stated it would be her responsibility to assist a patient in filing a grievance, but stated she did not know how.

c. An RN House Supervisor was interviewed on 10/26/16, beginning at 11:05 AM. He stated he would go to the DON for help in resolving complaints. The RN House Supervisor stated he was unsure how to assist a patient in filing a grievance. He stated complaints regarding patient care received via telephone were not entered into the incident reporting system and were not being tracked.

d. An OT was interviewed on 10/26/16, beginning at 3:50 PM. She stated she did not know the difference between a patient complaint and grievance. The OT stated she did not recall receiving complaint/grievance training. She stated she would refer all patient complaints to the patient's RN for entry in the incident reporting system and resolution. The OT stated she would not document complaint issues, but would follow-up with nursing regarding resolution.

e. A PT was interviewed on 10/26/16, beginning at 3:35 PM. He stated he did not know the difference between a patient complaint and grievance. The PT stated patient complaints should go to the proper discipline and up the chain of command. He stated he would not document patient complaints in the incident report system and remarked "I'm not the complaint department."

f. The Hospital Administrator was interviewed on 10/26/16, beginning at 3:45 PM. He stated all staff should enter all complaints in the incident reporting system.

g. A PCT was interviewed on 10/27/16, beginning at 8:45 AM. She stated complaints would only be entered in the incident reporting system if they required interventions and was unsure if all complaints should be entered. The PCT stated she would refer the complaints to the patient's RN for help.

The Area Director of Compliance was interviewed on 10/27/16, beginning at 10:10 AM. She confirmed the staff answers regarding complaints, grievances, and the grievance process were inconsistent, did not follow hospital policy, and could impact patients' rights.

The Hospital Administrator was interviewed again on 10/27/16, beginning at 10:30 AM. He confirmed the staff answers regarding complaints, grievances, and the grievance process were inconsistent, did not follow hospital policy, and could impact patients' rights. The Hospital Administrator acknowledged complaints were not being reported via the incident report system, and the complaints which were entered were not analyzed and captured as grievances. The Hospital Administrator confirmed there was no documentation in Leadership Meeting or Governing Body Meeting minutes related to the ongoing assessment or evaluation of the hospital grievance process.

The hospital governing body failed to ensure that the effective operation of the grievance process included staff education and compliance to the hospital's policies and grievance process.

Based on patients' rights review, hospital policy review, hospital document review, staff interview, and patient interview, it was determined the hospital failed to ensure a clearly explained procedure was established for the submission of a patient's written or verbal grievance for 2 of 3 inpatients (#9 and #10). This had the potential to interfere with the submission of a complaint or grievance for all patients/representatives who wanted to submit a written complaint/grievance to the hospital. Findings include:

A hospital document "Patient's Rights," dated 12/2013, was reviewed. The document included:

- "If you wish to file a formal complaint or grievance during or after your discharge, please contact the Hospital Administrator..."

A hospital document for new hire orientation, untitled and undated, regarding patient complaints and grievances, was reviewed. The document included:

- "Complaint - Patient issues that can be resolve [sic] promptly or within 24 hours"
- "Involve staff who are present at the time of the complaint"
- "Typically involve minor issues"

The document did not include how staff could assist a patient in submitting a verbal or written grievance.

A hospital policy "Resolution of Patient Complaints/ Grievances," dated 9/2013, was reviewed. The policy included:

- "When the staff present are unable to resolve an issue: if a 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 actions for resolution, then the complaint is a grievance."
- "The Governing Body delegates the responsibility for the resolution of patient grievances to the administrator of the hospital. The administrator shall implement the processes outlined within the policy."

A second hospital policy "Incident Reporting," dated 9/2013, was reviewed. The policy included:

- "The staff that witnessed or discovered an unusual incident or occurrence (event) or received a patient or visitor complaint must complete the incident report PRIOR [sic] to the end of their shift."

Two of 3 alert and oriented inpatients interviewed were unable to verbalize to whom in the hospital they could submit a verbal or written grievance. The hospital failed to effectively educate inpatients on the formal grievance process. Examples follow:

1. Patient #9 was an 86 year old female who was admitted on 10/16/16, with a diagnosis of a right total knee arthroplasty. Patient #9 was interviewed on 10/26/16, beginning at 11:33 AM. When asked if she knew who she could speak to in the hospital regarding a complaint or grievance, Patient #9 stated she did not know. Patient #9 stated she did not recall staff explaining the complaint or grievance process to her. When asked if she had a copy of her hospital's patients' rights, Patient #9 stated she was unsure.

2. Patient #10 was a 53 year old female who was admitted on 10/25/16, with a diagnosis of multiple sclerosis (a disease of the central nervous system) exacerbation and urinary tract infection. Patient #10 was interviewed on 10/26/16, beginning at 3:05 PM. When asked if she knew who she could speak to in the hospital regarding a complaint or grievance, Patient #10 stated she did not know. Patient #10 stated she did not recall staff explaining the complaint or grievance process to her. When asked if she had a copy of her hospital's patients' rights, Patient #10 stated she was unsure.

The Hospital Administrator was interviewed again on 10/27/16, beginning at 10:30 AM. He confirmed the staff answers regarding complaints, grievances, and the grievance process were inconsistent, did not follow hospital policy, and could impact patients' rights. The Hospital Administrator acknowledged the complaint and grievance process explanation to patients was not consistently effective.

The hospital failed to clearly explain the grievance process to patients.

Based on hospital policy review, hospital document review, grievance document review, and staff interview, it was determined the hospital failed to ensure the written notice provided to patients or their legal representatives included all steps of the grievance resolution for 7 of 8 patients (#18, #19, #20, #21, #22, #23, and #24) whose grievance resolution documents were reviewed. This resulted in an incomplete resolution to the grievance process. Findings include:

A hospital document for new hire orientation, untitled and undated, regarding patient complaints and grievances, was reviewed. The document included:

- "Date of completion/closure of the grievance"

A hospital policy "Resolution of Patient Complaints/Grievances," dated 9/2013, was reviewed. The policy included:

- "The date of completion/closure of the grievance"

The hospital failed to follow their policy and grievance process to ensure all grievance response elements were met. Examples include:

1. A "ComplyTrack" grievance report for Patient #18, dated 1/21/16, was reviewed. A grievance response letter was mailed to Patient #18 on 2/01/16; however the letter did not include the date the grievance investigation was completed.

2. A "ComplyTrack" grievance report for Patient #19, dated 3/15/16, was reviewed. A grievance response letter was mailed to Patient #19 on 3/30/16; however the letter did not include the date the grievance investigation was completed.

3. A "ComplyTrack" grievance report for Patient #20, dated 4/07/16, was reviewed. A grievance response letter was mailed to Patient #20 on 4/19/16; however the letter did not include the date the grievance investigation was completed.

4. A "ComplyTrack" grievance report for Patient #21, dated 7/22/16, was reviewed. A grievance response letter was mailed to Patient #21 on 8/04/16; however the letter did not include the date the grievance investigation was completed.

5. A "ComplyTrack" grievance report for Patient #22, dated 8/26/16, was reviewed. A grievance response letter was mailed to Patient #22 on 9/02/16; however the letter did not include the date the grievance investigation was completed.

6. A "ComplyTrack" grievance report for Patient #23, dated 9/28/16, was reviewed. A grievance response letter was mailed to Patient #23 on 10/12/16; however the letter did not include the date the grievance investigation was completed.

7. A "ComplyTrack" grievance report for Patient #24, dated 3/23/16, was reviewed. A grievance response letter was mailed to Patient #24 on 3/30/16; however the letter did not include the date the grievance investigation was completed.

The Director of Compliance and the Area Director of Compliance were interviewed on 10/26/16, beginning at 1:30 PM. They confirmed the grievance response letters did not document the date the grievance investigations were completed.

The hospital failed to follow their policy and grievance process to ensure all grievance response elements were met.