HospitalInspections.org

Based on medical record review, quality document review, incident report review, policy review, and staff interview, it was determined the hospital failed to ensure grievances were identified and promptly resolved for 1 of 1 patients (Patient #3) whose representative submitted a verbal grievance, and whose record was reviewed. This resulted in quality of care resolutions not provided to a patient's representative. Findings include:

A hospital policy, "Complaint and Grievance Process," reviewed 2/2021, stated:

- "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with regulatory requirements are considered grievances."

- "All concerns, complaints or inquiries whether resolved or not at the point of the complaint will be entered into the hospital's incident reporting system."

- "Written notice of grievance resolution and decisions made is provided to complainants and contains the following: Name of Vibra Hospital's contact person...Steps taken on behalf of the patient to investigate the grievance...Results of the grievance process...Date of completion."

- "Staff member receiving the complaint...The Patient Complaint is entered into the Incident [sic] reporting system for all complaints received, whether concerns/dissatisfaction by end of the shift...All information/sections in the hospital's incident reporting system will be completed when entering a complaint. If the patient is not the person making the complaint, enter the name, relationship to the patient, and the contact information of the complainant into the incident reporting system to allow for appropriate follow up [sic] contact."

This policy was not followed.

Patient #3 was a 71 year old female who was admitted to the hospital on 1/14/21, with a primary diagnosis of acute respiratory failure due to COVID-19. She was discharged home with home health on 2/16/21.

The hospital's incident report log from 1/01/21 to 4/01/21 was reviewed. The log included "Incident #92703," dated 2/16/21, which detailed quality of care and discharge planning issues for Patient #3. The incident report was entered by the hospital's Director of Pharmacy and included a grievance submitted verbally by Patient #3's representative. The incident was entered as "Patient Advocacy," but not flagged as a grievance. It could not be determined if the grievance was identified, investigated, and resolved.

The Director of Pharmacy was interviewed on 4/20/21, beginning at 12:44 PM, and Patient #3's incident report was reviewed in her presence. She stated one of her pharmacists was the person who took the phone call from Patient #3's representative and documented her concerns. The Director of Pharmacy stated the pharmacist relayed Patient #3's representative's concerns to her and she filled out an incident report based upon his information. She stated she did not recognize Patient #3's representative's concerns as a grievance. Additionally, the Director of Pharmacy confirmed her pharmacist did not recognize Patient #3's representative's concerns as a grievance. The Director of Pharmacy confirmed hospital policy was not followed.

The Director of Quality was interviewed on 4/20/21, beginning at 1:02 PM, and Patient #3's incident report was reviewed in his presence. He confirmed Patient #3's representative's concerns were not identified as a grievance, so an investigation and resolutions to the quality of care and discharge allegations were not resolved.

Patient #3's case manager, who facilitated her discharge planning and discharge, was interviewed on 4/20/21, beginning at 1:36 PM, and Patient #3's medical record was reviewed in her presence. She stated she had received a phone call from Patient #3's representative on 2/17/21 regarding quality of care and discharge concerns. The case manager stated she did not recognize Patient #3's representative's concerns as a grievance and failed to enter the issue into the hospital's incident report tracking system. She confirmed she did not follow hospital policy.

The hospital failed to identify and resolve a verbal grievance submitted by Patient #3's representative.