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Based on interview and record review the facility failed to ensure the investigation into a complaint voiced by a patient's representative was communicated with the complainant, as the facility policy required.

Findings were:

Review of the facility provided policy titled HD Manual Page 4 of 7 Management and Leadership Original Date: 01/2001

Section 04 Risk Management Confidential and Proprietary Information

2. Grievance: Is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative regarding any aspect of the patient's care, account or other aspect of the stay than cannot be resolved on the spot by the staff present.

e. COPY the complaint form and place the copy in a secured file drawer.
f. Provide the original form (in person) to the investigator in a file folder marked as follows: "Confidential and Privileged Quality Improvement Information" .

During an interview on the morning of 3/6/18 Staff #1, Quality Director stated the incident was not completed by her. Staff #1 further stated, "...I talked to the Daughter once in the hallway I don't remember about what just that she was upset.

Staff #1 was asked if she was suppose to have a copy of the investigation. she stated, "Yes, but I was never given it".

Based on interview and record review the facility failed to ensure compliance to its grievance policy in one of one sampled patients with documented grievances (patient #1).

The patient did not receive timely post-investigation communication (phone, meeting, formal written acknowledgement) as indicated in the hospital policy.

Findings:

Interview on 3/6/2018 with the Risk Manager Quality Improvement staff revealed, patient #1 did not recieve an investigation into complaint as indicated by hospital policy.
Patient Complaint/Grievance Process H-ML 04-008
Release Date: 06/2017
HD Manual Page 4 of 7 Management and Leadership
Original Date: 01/2001

Section 04 Risk Management Confidential and Proprietary Information
1) The compliant or grievance is reported promptly
2) Investigation was appropriate
3) Timely patient and/or family communication
4) Recommendations for improvement are discussed
5) Consistent patient rounding (two or more times per week)
6) Identification of any previous customer service issues or concerns
7) Complaints and grievances are monitored during Flash meetings
8) Event reports are filed as appropriate

Record review of the facility policy Complaint/Grievance, Hospital Response dated 06/2017 stated NOTE: It is recommended to communicate the assignment, expected deadline for completion and distribute the form at the morning meeting, allowing sufficient time to complete a written response.
h. Once the investigation is complete:
i. Bring the conclusion to the morning meeting if appropriate.
ii. Determine actions taken or what action will be taken.
iii. Confirm that the form has been completed (and event report, if applicable).
iv. Complete the complaint log with the conclusion and action.
v. Complete review to ensure:
1) The compliant or grievance is reported promptly
2) Investigation was appropriate
3) Timely patient and/or family communication
4) Recommendations for improvement are discussed
5) Consistent patient rounding (two or more times per week)
6) Identification of any previous customer service issues or concerns
7) Complaints and grievances are monitored during Flash meetings
8) Event reports are filed as appropriate
i. Once an action has been taken:
ii. Assure the complaining party is aware of the investigation results and actions taken. ii. If it is a grievance, face to face (preferred) or verbal contact should be made with the complainant to discuss the investigation and action taken before the written response (CEO letter) is sent. This communication should be made by the CEO or their designee (CCO, DQM, Department Manager, etc.)

Based on record review and interview, the facility failed to enforce its grievance policy # Patient Complaint/Grievance Process H-ML 04-008 and respond in writing when a patient made a complaint to facility staff expressing dissatisfaction with the care and services she received during her hospital admission. Citing one (1) patient named in a complaint.( Patient # 1).

Findings:

The facility failed to ensure a proper investigation into a complaint that was made as evidenced by:
1. no documentation of the complaint in the complaint log.
2. no documentation of the investigation.
3. no follow up written letter indicating outcome.
4. failure to investigate and esculate complaint when another complaint was filed with the Nursing Boards, Joint Commission, and OIG.

Patient Complaint/Grievance Process H-ML 04-008
Release Date: 06/2017
HD Manual Page 3 of 7 Management and Leadership
Original Date: 01/2001
Section 04 Risk Management Confidential and Proprietary Information
their immediate supervisor, noting the issue, how it was or was not resolved and any further recommended actions.

4. Investigation and Completion of the Complaint or Grievance. Supervisor/Department Manager Review and Documentation:
a. It is the supervisor's responsibility to handle unresolved complaints or grievances promptly and effectively resolve them.
b. If the issue is not resolved immediately by those present, it is considered to be a grievance. The supervisor must:
i. Initiate an initial investigation if it has not already been started, including interviews of individuals with information about the issue (patient, family, staff, etc.)

ii. Initiate the Complaint and Grievance form. Concisely describe the issue and
actions taken. The assigned investigator will also need to add information on the
back of the form.
iii. Notify the DQM by calling the risk hotline.
iv. All completed complaint forms should be placed in the DQM's mailbox by the end
of the shift.
v. Communicate the status of the investigation to the patient and/or individual who
reported the issue. ? NOTE: In some cases, a complainant may not be entitled to a f
ull explanation of the status (either because they are not an authorized representative,
the information is HIPAA-protected, etc.

Report any concerns to the Department Manager, or consult with the DQM.

c. Notify (If the complaint is resolved on-the-spot with staff present)

i. Once an issue is resolved, call the DQM Hotline to report that the complaint was made and what was done to resolve it. Provide the following information:

1) Name of patient or other person who complained
2) Day and time the complaint was made
3) The nature of the complaint
4) How the complaint was resolved
5) What information or feedback has been provided to the patient or complainant

d. Escalate (If the complaint is not resolved immediately)

ii. Every issue, concern, or expression of dissatisfaction that cannot be resolved by you should be escalated to a supervisor, manager or administrator.
iii. The severity of the issue or concern dictates how much of a delay is tolerable; however, all unresolved issues must be reported to the supervisor immediately.

5. DQM Responsibilities
a. Enter all patient names in the complaint log when notified either by the risk hotline or by receipt of a complaint form.
b. Determine whether the issue is a complaint or grievance and check the appropriate box.
c. Determine whether the issue is an "event" requiring reporting according to policy. For example, a complaint that alleges rough physical handling of a patient, or verbal bullying should be handled as an event. Note: an issue can sometimes trigger treatment both as a grievance and an event. H-ML 04-001 Event Reporting System H-ML 04-003 Investigating Serious and Sentinel Events

Based on review and interview, the facility failed to identify and take actions aimed at performance improvement and, measure its success, and track performance to ensure that improvements are made to ensure quality care is given.

Review of patient #1 chart dated 8/12/2016 to 8/15/16 revealed that vital signs were not taken when a patient had a change in condition. this failure to assess vital signs on a patient could effect patient outcomes.

review of patient quality improvement for 2017/2018 indicated that ensuring the assessment/re-assessment of vital signs is not part of their quality Improvement program for continuel review.