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Based on the complainant and Patient 1 interview, the hospital failed to ensure prompt resolution of complaints and grievance for patient 1 and family member. The hospital failed to ensure:

A. Complaints, made by patient 1 and complainant regarding care, were not thoroughly investigated.

B. Patient care feedback made by complainant and patient 1 were not properly identified as a complaint/grievance, logged in the complaint/grievance log, and thoroughly investigated and resolved on patient 1.

Findings include:

During the complainant interview on 7/11/2025 at 9:45 am it was discovered that the complainant spoke to the nursing staff over the phone with complaints about the daily care and therapy issues regarding patient 1. The complainant stated that she was told that she would hear from management about her concerns. The complainant stated that she never received a call back. She stated that she called the facility to complaint about the lack of responsiveness and was transferred to staff 1. The complainant stated that staff 1 listened to her complaints and was told by staff 1 that she would "look into the matter". The complainant never received a call back. The complainant stated that patient 1 had to be transferred to a hospital due to worsening condition and she was unable to follow up regarding her concerns.

During Patient 1's interview on 7/11/2025 at 1:45 pm it was discovered that the patient had voiced several complaints regarding his care to the staff. He also stated that he spoke to a female executive regarding his complaints of care when she rounded on patients. He stated that he was told his complaints would be investigated. He stated that he did not receive a follow up. He was unable to follow up as his condition deteriorated and he was emergingly transferred out to a higher level of care facility.

The interview with the quality department staff revealed that no complaints had been recorded in their online reporting system by any staff member regarding patient 1.


Review of a facility's policy named: "Patient/Family Complaint" Policy number: QM 9, revised on 10/21/2024 revealed the following:

"IV. Procedures, 2. Complaints/concerns may be presented to any staff member ...", 3. A report of the complaint is entered as an incident by the staff member who receives the information. The supervisor and Director of Quality are notified of the complaint through the online reporting system or via staff. 5 ....All interaction with the patient/family regarding the complaint will be documented in the incident document".