HospitalInspections.org

Based on review of records and interviews the facility failed to follow its policy and procedure "Patient Grievance Policy / Complaint Resolution" to ensure patient complaints, grievances, or allegations of abuse or neglect were documented and processed in a timely manner fashion in 1 of 1 patient's (Patient # 1) record reviewed.

A review of patient #1's chart revealed she was admitted to the facility on 6/5/25 for Sepsis and End Stage renal disease requiring hemodialysis with a history of end stage renal disease, high risk for pressure injury of skin, diabetic ulcer of right foot, diabetic ulcer of left foot, Diabetic neuropathy, generalized abdominal pain, Class 1 obesity, Diabetes mellitus type 2 and difficulty walking.


Patient #1, a 52 y/o female, presented to the ER with a history of end stage renal disease (ESRD) on peritoneal dialysis, nausea vomiting and diarrhea for 3 weeks. Patient #1 reported unknowingly injecting Ozempic daily instead of weekly and found to be sepsis secondary to acute cystitis with nausea, vomiting and diarrhea. The patient was admitted and treated with antibiotics, started on hemodialysis and had consultations for wound care and physical therapy and occupational therapy. The patient was discharged on 6/12/2025 to home with family.

A review of the patient rounding log revealed that on 6/12/2025 at 9:53 AM patient #1 complained to the patient experience representative that she was left soiled for a long time and not cleaned until 6 am and that she wanted pain medication but was not administered any because she had been given pain medication already.

The Medication Administration record for 6/11/2025 shows that she was medicated for pain at 11:28 PM. Reassessment done at 02:04 AM.

There was no incident report, or a complaint or grievance entered for patient #1 concerning her complaints. The patient experience log showed that the charge nurse was notified, and that the unit director would be informed of the incident.

No follow up with patient #1 was found. No documentation that the complaint was process as an unresolved complaint. (Look at this sentence so that it's clearer to the reader)

A review of the policy and procedure " Patient Grievance Policy / Complaint Resolution" states,

"POLICY
It is DHR's policy to document, address and resolve all verbal or written grievances received from patients, families, visitors, and other customers in a timely manner.
DEFINITIONS
Grievance: a formal or informal written or verbal complaint that is made to OHR or OHR employees by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to DHR's compliance with the CMS Hospital Conditions of Participation (COPs), or a Medicare beneficiary billing complaint.
Verbal Complaint: a verbal complaint is a patient grievance if:
A. The complaint involves abuse, neglect, patient harm, or hospital compliance with COPs.
B. It cannot be resolved at the time of the complaint by staff present.
C. Is postponed for later resolution.
D. Is referred to other staff for later resolution; or
E. Requires investigation and/or requires further actions for resolution."


"PROCEDURE:
...3. Any OHR employee who receives a grievance from a patient, family, visitor or other customer will proceed as follows:
i. Immediately attempt to resolve the identified concerns on the spot at the time the grievance is received.
A. Grievances involving situations or practices that place the patient in immediate danger should be referred to the Charge Nurse or the department Director for immediate resolution.
B. Grievances alleging patient, family member or visitor harm or those threatening legal action should be immediately forwarded to Quality Compliance Department and/or the Risk Management Department.
ii. If unable to resolve the identified grievance at the time it is received
(i.e., requires investigation or requires further action for resolution), then the OHR employee or department Director will immediately contact the Guest Relations Director who will document the grievance on the Service Recovery Form and attempt to resolve the issue and/or will involve appropriate hospital personnel for follow-up actions ....

v. All grievances shall be attempted to be resolved within seven (7) business days from the date of grievance. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) days from grievance receipt from the patient, family member or visitor, then the Patient Grievance Committee shall inform the patient, family member or visitor that OHR is still working to resolve the grievance and that OHR will follow-up with a written response within (30) thirty business days."