HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patients' grievances reviewed, the Hospital failed to ensure that a patient grievance was reviewed and resolved as required.

Findings include:

1. The Hospital's policy titled, "Patient Complaint and Grievance" (revised 10/18), included, " ...II. Complaint: An expression of dissatisfaction by a patient, family member ... about the care of services that can be resolved by "staff present" at the time of the complaint or by management associate(s) who can quickly respond to the complainant's location ... III. Grievance: A. A complaint regarding the patient's care that is received formally or informally ... either verbally, via telephone ... 1. Complaints that were not resolved at the time turn into grievances when ... e. The complaint requires investigation. 2. Examples of grievances ... c. Complainant requests to file a formal complaint or grievance ..."

2. On 6/01/2021 at approximately 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 12/11/2020 and discharged 12/18/2020 with a diagnoses of constipation and hypoxia (low oxygen level).

3. On 6/1/2021 at approximately 10:20 AM, the Hospital provided an email dated 12/30/2020 at 9:31 AM, and included, "To: (Patient Safety Specialist E #2) ... Subject: Family Complaint ... (name of Pt. #1's daughter) left a message about her mother (Pt. #1) ... being discharged with bedsores (daughter) said the Home Health nurses have told her they 'can't believe she was discharged in this condition' ... email response from (E #2) dated 12/30/2020 at 12:44 PM, included, "I (E #2) did speak with the daughter and she has my contact information should she need anything moving forward. At this time, I believe my conversation with her was adequate and this can be closed on your end ..."

4. The Patient Grievance Log from 1/1/2020-6/1/2021 was reviewed on 6/1/2021. The log did not list a grievance for Pt. #1.

5. On 6/1/2021 at approximately 12:30 PM, an interview was conducted with the Patient Safety Specialist (E #2). E #2 stated, "I recall speaking to (Pt. #1's) daughter in late December, I do not recall speaking to her again. She explained that she had concerns that (Pt. #1) had a wound and felt that it developed during (Pt. #1's) hospitalization. I reviewed (Pt. #1's) chart and interviewed the discharge nurse, and there was no indication that there were any wounds to buttocks. After our conversation I felt the issue was resolved and she was satisfied. In all honesty I do not have any documentation of the conversations we had, and I considered this as a closed complaint." E #2 stated that there was no documentation of an investigation conducted of Pt.#1's daughter complaint.