HospitalInspections.org

Based on record review and interview, the facility's Director of 2 South telemetry unit failed to follow the facility's complaint and grievance policy when a patient's family member verbalized a complaint about the healthcare for 1 (#9) of 3 patients.

Findings:

A review of the facility's complaint and grievances log revealed no evidence that a complaint had been filed by staff or family members for patient #9.

An interview was conducted with Staff #3 on 10/18/2023 after 11:00 AM. Staff #3 was asked if a complaint was received from patient #9. Staff #3 stated, "Yes, the family was complaining about the patient not being transferred to the Intensive Care Unit (ICU) because they felt they needed to be more closely monitored because he was on an amiodarone drip (a medication used to prevent and treat a fast irregular heart rate). The Intensivist (a critical care doctor) determined that the patient was stable hemodynamically and could be monitored on the telemetry floor. Patient #9 was not on a titratable drip of amiodarone. I went and talked to the patient's daughter, and clearly she was upset. I went and talked to the Critical Care Nurse Practitioner and told her the concerns of the family and she agreed to admit the patient to the ICU. I informed the daughter that we were going to do that, and she told me that he was being transferred to another hospital because that is where his cardiologist was. At this time, she was still upset, and I assured her that we were able to care for him here, but she insisted that he was going to be transferred."

An interview was conducted with Staff #1 on 10/18/2023 after 11:00 AM, and it was confirmed there was not a grievance filed with the hospital and the complaint appeared settled at the time so there was no further action.

A review of the facility's policy titled, "Complaint/Grievance Resolution Process For Patients." dated 05/21 revealed the following:

"GUIDELINES:

I. Patients receive notice of their rights and are informed of the grievance or complaint process through signs that are posted in all patient intake areas.

2. Notification of the grievance or complaint process includes information regarding who to contact within the hospital and also provides the patient with a telephone number and address for lodging a grievance or complaint with the
Department of State Health Services, regardless of whether the patient has first used the hospital's grievance/complaint process. Taking the initiative to problem solve and provide service recovery is every
staff/associate's responsibility. Any staff/associate who encounters a dissatisfied guest may use the following guidelines to handle the complaint on the spot or with assistance as necessary.

C- Connect to the emotions the patient/family are experiencing.
A - Apologize
R - Resolve the issue
E - Express gratitude

3. If the complaint is resolved at the level of service, the staff/associate present are required to enter the complaint into Midas Patient Relations or fill out the Customer Concern Form providing the patient's name, date, brief description of complaint and steps taken to resolve. A copy of the Customer Concern Form will be given to the associate's manager and the Patient Advocate as soon as possible or at the end of the associate's shift when the complaint was communicated. The "Customer Concern Forms" will be monitored by the Patient
Advocate and/or Administrative Director of Nursing Operations for additional follow up actions necessary and will be responsible for tracking and trending grievances and complaints.

4. If a patient care complaint cannot be resolved at the time of the complaint by staff/associate present is postponed for later resolution, is referred to other staff/associate for later resolution requires investigation, and/or requires further
actions for resolution, the complaint is a grievance. For tracking and trending purposes, grievance, and/or complaint classification should be determined by the following guidelines:

a. MINOR - Patient frustrated but assumes the situation is part of the healthcare experience.

b. MODERATE - Patient/family member voice their concern(s) and seek service recovery.

c. MAJOR- patient/family member is very angry and may have filed a formal grievance; results in harm or could potentially have resulted in harm; multiple occurrences with the same patient."

An interview was conducted on the morning of 10/18/2023 with Staff #1 and Staff #14 about how a staff member would process a complaint. Staff #1 and Staff #14 stated, "There has not been any annual staff training regarding the complaint and grievance policy."

An interview with Staff #3 on 10/18/2023 after 11:00 AM confirmed there was not any documentation regarding the complaint from patient #9's family or documentation of any interactions with the family. Staff # 3 stated, "The complaint was not documented anywhere and no one else was notified." Also, Staff #3 acknowledged that the facility policy "Complaint/Grievance Resolution Process For Patients" was not followed.