HospitalInspections.org

Based on a review of facility documentation, policy review, and staff interview the facility failed to follow its own policy and procedure regarding patient grievances when it received a verbal complaint regarding patient care and there was no documentation of follow up and resolution.

Findings were:

A review of the clinical records revealed that for 1 of 1 patient (patient #1) making a verbal complaint regarding patient care, the facility failed to either resolve the issue immediately or implement its own grievance procedure.

Facility policy titled "Patient Complaint/Grievance" states "Purpose: To provide a uniform mechanism for receiving, managing, and properly resolving patient and family/visitor grievances, complaints, concerns or dissatisfactions in a timely manner. Policy: The department/service unit is expected to resolve the complaint whenever possible at the time the complaint is raised. If prompt resolution is not possible it becomes a formal grievance, and is managed accordingly. Definitions: Patient complaint-Concern/Dissatisfaction: A verbal expression of concern or dissatisfaction with a service or department within the facility that is more substantive than a minor request, and is resolved by the staff present to the satisfaction of the complainant on the department level at the point of the complaint. Patient complaint-Grievance: Any expression of dissatisfaction (verbal or written) related to an occurrence within the facility which is of such severity that it is not able to be resolved to the satisfaction of the complainant at a departmental level by the staff present. Complaints that require further investigation, further actions for resolution, or are postponed for later resolution are considered a grievance. Complaint type examples include: patient care; delays in service; facility policy or procedures; equipment issues-call buttons ....." Complaints are tracked for the purpose of trending, improving the processes, and ensuring customer satisfaction with follow-through. When a complaint either written, verbal or a grievance is received, the Director of Quality/Risk Management will initiate an investigation in collaboration with the staff and director of the involved department. Grievances are considered resolved when the complainant is satisfied with the actions taken. If appropriate and reasonable actions have been taken on the patient's behalf, yet the complainant remains unsatisfied with the facility's actions, the grievance is considered closed."

Review of the Grievance/Complaint Logs for the facility for the month of October 2014 revealed no documentation the patient ever had a complaint, concern, or grievance regarding call light system, leaving her in the restroom for over 45 minutes, or her concerns regarding the isolation for her medical condition.

Interview with the Chief Nursing Officer(CNO) confirmed she was unaware that patient #1 had voiced a complaint about the nurse call light system not functioning and that staff were not answering the call lights and leaving her in the restroom for about 45 minutes at a time. The CNO did acknowledge these concerns would fit under a patient complaint/grievance per facility policy and should have had the Patient Grievance/Complaint form filled out and resolution should have been documented on the form.