HospitalInspections.org

Based on review of policy, medical records, grievance log, and interviews with staff, the facility staff failed to acknowledge a patient's written complaint as a grievance and provide written response in 1 of 1 patient grievances identified (Patient #2).

The findings include:

Review of policy on 02/22/2023 titled "Complaint and Grievance Process" with reviewed date of 10/01/2020, revealed "POLICY: The hospital has established a mechanism for receiving, acting upon, and responding to patients and his or her representative, expressing concern for the patient's treatment and all areas of quality of care (the 'Grievance Process'). It is the policy of the Hospital to respond to such complaints promptly. It is also the policy of the Hospital to establish a process to respond to concerns and complaints and to assure patients and his or her representative, are aware of this process and their rights to access it....3. The patient and the patient's representative may inform the Hospital of a complaint or grievance verbally or in writing...If a complaint cannot be resolved timely the Hospital staff member, it will be considered a grievance. 7. CMS 482.13 (a)(2), defines a patient grievance as follows. A patient grievance may be a formal or informal written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present) ...9. The Director of Quality Management and/or Chief Nursing Officer will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO. The investigative procedure should be completed, corrective action taken, and a written response sent within 7 days of receipt of complaint. If the grievance will not be resolved or the investigation completed within 7 days, the hospital shall inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow -up with a written response in a stated number of days. If additional time is required, it will not extend beyond 30 days from receipt of the grievance....13. The written response must contain the following: a) A description of the issues raised by the grievance b) A description of the steps taken to investigate the issue c) The date the grievance was resolved and what steps were taken to resolve the grievance d) The name of a contact person at the hospital that the patient can call with additional questions...."

Review of Patient #2's discharge summary dated 12/20/2022 at 1140 revealed a 77-year-old female admitted on 11/16/2022 for recent CVA (stroke) which required right Hemicraniectomy/temporal lobectomy (removal of portions of the brain) on 09/24/2022 complicated by seizure disorder. Patient #2 was admitted for trach management, medical management of atrial fibrillation, and rehabilitation with PT/OT/ST (Physical therapy/Occupational Therapy/Speech Therapy-all personnel who assist with rehab of the patient). During her stay at (named hospital), she was successfully weaned from the trach and was decannulated (trach allowed to close). She also resumed an oral diet and weaned off tube feedings...."

Review of "Patient Complaint, Grievance or Abuse/Neglect" report created by DQM(Director of Quality Management) #2 dated 12/05/2022 revealed complaint listed for Patient #2. "I just received a call from (named daughter), Patient #2's daughter. She has expressed some concerns with her mother's care from our hospital team. 1. She has not been bathed since last Friday. Family actually requested a bath for their mom at this time. 2. She is NOT being turned every two hours. The CNAs(Certified Nursing Assistants) at night will come in press the button on the wall and leave the room. Her other daughter has been turning her herself with NO assistance from our team whatsoever. 3. She has a bedsore on her bottom, and it hasn't been look (sic) at let alone had a dressing change in over a week. 4. Inappropriate conversations in the room involving the CNA staff or nursing staff towards speech therapy...and entered the room mad that she had to change Patient #2...(speech called out to let the team know she had a BM(bowel movement) and needed to be changed and when they came in they were talking amongst themselves stating, "I don't know why she couldn't have done it herself"). 5. Family and patient have asked for Tylenol--for pain and its taking the nursing staff 2 + hours to get it to her. This family expressed the concern stating they don't want anyone to be mad at them and they are worried that they will be treated poorly and that her mothers (sic) care will be compromised." Further review of the complaint information form revealed "What immediate corrective action was taken to resolve the complaint? CNO(Clinical Nursing Officer) followed up with family. Family gave positive feedback about staff. Was issue resolved timely without need for further investigation? Yes." Review revealed Patient #2's family concerns were written in the complaint investigation form by the DQM #2. Review revealed no documentation of investigation of a grievance.

Interview on 02/23/2023 at 1350 with CNO #1 revealed complaints are easily resolved and require no further involvement. Interview revealed all of the information received from the daughter were treated as complaints. Interview revealed after immediate review all of the information required investigation and should have been treated as a grievance. Interview revealed a letter should have been sent to the family after an investigation. Interview revealed the grievance process and policy was not followed. Interview revealed the CNO did not perform a grievance investigation into the family's complaints. Interview revealed all 5 written complaints from the family were actions that needed more investigation and should have been treated like a grievance.

Interview on 02/23/2023 at 1352 with DQM #2 revealed the information from the family was written on the form by DQM #2. Interview revealed the information from the family was received by phone and written on the complaint form. Interview revealed the issues from the family should have been investigated and a letter should have been sent to the pt(patient) or representative. Interview revealed the grievance policy was not followed.

NC00188182
NC00185485