HospitalInspections.org

Based on record review and interview, the facility failed to have an active process for prompt resolution of patient grievances, as shown by the lack of an active mechanism for handling complaints and grievances. The facility failed to:

a) Keep complaint/grievance data for the first three months of 2025 and produce any evidence that data was collected for patient and family grievances for January, February and March of 2025. There was also no Grievance log available for this time period;

b) Produce any evidence that patient complaints were addressed for the first three months of 2025, and;

c) Effectively monitor the Patient Advocate's activities-the person responsible for managing the facility's complaints and grievances-to ensure that complaints and grievances were being addressed.


Findings included:


Review of facility policy (no ID#) titled "Patient & Family Complaints & Grievances", last revised 3/1/19 showed the following: The facility will provide an effective mechanism for handling patient & family complaints. In addition, the facility's Patient Advocate: acts as the liaison between patient and facility to facilitate problem-solving actions; facilitates the investigation of complaints and grievances to help resolve them in a timely manner; informs the complainant once the issue is resolved; presents a report to the Performance Improvement committee for review and to decide if further action is necessary. The policy also states that data from complaints and grievances are aggregated and used as part of the organization's performance improvement activities.

In an interview in the facility's conference room on the afternoon of 4/1/25 after requesting the facility's Complaint & Grievance logs, DRM Staff #B, CCO Staff #C and other staff stated there was no longer a facility Patient Advocate.

In an interview on 4/2/25 at 9:30 am, DRM Staff #B stated there was no available complaint data or other information available since part of December of 2024 through all of March, 2025 inclusive. Staff #B added that the facility's Patient Advocate, Staff #M, was responsible for handling complaints and grievances and was no longer employed starting in February, 2025.

Record review of Patient Advocate Staff #M's HR files showed he was terminated from employment 3/3/25 and was not eligible for re-hire. There were no exact reasons listed as to why he was terminated.

In an interview on 4/2/25 at 3:30 pm, DRM Staff #M stated the reason for the termination of the patient advocate was due to him not performing his job duties adequately.