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Based on interviews, a review of documentation, and a review of policies and procedures, the facility failed to ensure a grievance voiced by a patient/patient representative had been investigated/resolved in accordance with the facility's policies and procedures for one (1) of three (3) patients selected for review. According to the facility's policies, if a complaint, written or verbal, could not be resolved at the time of the complaint by staff present, and/or required investigation, then the complaint was considered a grievance for the purpose of the requirements of the facility's policy and required investigation and a report of the facility's investigation to the complainant.

The findings include:

Interview with a representative of patient #1 on May 21, 2010, at 2:44 p.m., revealed patient #1's representative had contacted the Administrator of the facility by telephone on March 5, 2010, or on March 12, 2010, and had voiced a complaint regarding the care/services patient #1 had received during a visit to the facility's Emergency Department (ED) on February 20, 2010. The patient's representative reported the Administrator had stated he/she would review the patient's medical record and call the patient's representative back. However, according to the patient's representative, the Administrator did not call back. The patient's representative reportedly made another telephone call to the Administrator the following week, had received a recorded message, and had left a message for the Administrator to call the patient's representative. According to the patient's representative, following the second call to the Administrator's office a representative of the facility returned the telephone call and advised the patient's representative that a facility form would need to be completed in order to file the grievance. The representative of patient #1 stated the hospital employee stated the facility forms would be mailed to the patient's representative to complete. However, according to the patient's representative, the paperwork was never received. The patient's representative stated in interview that the facility's representative had been informed that the patient's representative had wished to file a complaint. In addition, the patient's representative stated that the facility had failed to provide a response to the voiced complaint.

On the day of the visit, the Administrator was unavailable for interview.

Interview with the Corporate Compliance/Regulatory Affairs Officer (CCRAO) on May 19, 2010, at 5:14 p.m., confirmed the CCRAO had been informed that a representative of patient #1 had contacted the Administrator and had complained about the care/services patient #1 had received in the Emergency Department on February 20, 2010. The CCRAO reportedly contacted the patient's representative and informed the representative that the patient's care/services received in the ED would be reviewed. The CCRAO stated the patient's representative had not requested that a "formal" complaint be filed. According to the CCRAO, if a patient's concern can be resolved "on the spot," the complaint is not considered a "formal" complaint and a follow-up is not needed. According to the CCRAO, the patient's representative was told the facility would look into the matter and the representative had seemed to be satisfied with the response.

A review of the facility's policies/procedures revealed a grievance policy had been developed in order to define a method for addressing patient grievances. According to the policy, a patient issue is not a grievance if the patient issue can be resolved promptly, on the spot, by staff present. The policy stated that patient grievances included situations where patients or the patient's representative phone or write to the facility about concerns related to care or services. According to the policy, if the complaint, written or verbal, cannot be resolved at the time of the complaint by staff present, is postponed/referred to other staff for later resolution, required investigation, and/or required further actions for resolution, then the complaint would be considered a grievance for the purpose of the requirements of the policy.

Based on interviews and a review of the facility's policies and procedures, the representative of patient #1 had offered a verbal complaint to the Administrator about the care/services the patient received in the ED. According to interviews, the Administrator had been unable to resolve the issue "on the spot" as defined in the facility policies, and had referred the complaint to the facility's CCRAO. Interview with the CCRAO on May 19, 2010, at 5:14 p.m., confirmed the CCRAO had received information related to the complaint voiced by patient #1's representative and had spoken to the patient's representative about the complaint. The CCRAO informed the patient's representative that the CCRAO would "look into" the complaint and had considered the complaint resolved "on the spot." However, in accordance with the facility's policy, if a complaint, written or verbal, cannot be resolved at the time of the complaint by staff present, is postponed/referred to other staff for later resolution, required investigation, and/or required further actions for resolution, then the complaint would be considered a grievance for the purpose of the requirements of the policy and required investigation and a report of the facility's investigation to the complainant. Based on interviews, the facility's Administrator failed to resolve the patient representative's complaint "on the spot," and had referred the complaint to the CCRAO for investigation. In addition, the CCRAO had informed the representative of patient #1 that the complaint would be "looked into." According to the facility's policies, if a complaint, written or verbal, cannot be resolved at the time of the complaint by staff present, and/or required investigation (looked into), then the complaint was considered a grievance for the purpose of the requirements of the facility's policy and required investigation and a report of the facility's investigation to the complainant.