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Based on interview, policy review and record review, the hospital failed to implement it's policies/procedures related to Patient Complaints and Grievances for 1 of 10 patients in the total sample. (Patient # 1). Findings include:

Per review of a written grievance sent to the hospital by a patient advocate dated 2/18/18, Patient #1 was filing a formal complaint related to care received in the Emergency Department on a recent date. The letter explained that the patient felt they were not treated with consideration and respect and that their rights were violated. The written complaint included an address and telephone number for the complainant. A copy of the grievance was also sent to the Licensing Agency. Per a telephone call to the complainant on 3/22/18, the complainant verified to the state investigator that they had no response of any kind from the hospital regarding their complaint.
During the on-site survey, it was determined that Patient #1 was treated in the ED during the month of January, 2018. Per interviews with the Director of Quality Assurance and a Risk Management Specialist, it was confirmed that the patient came to the hospital on 1/19/18 to give a verbal complaint regarding the ED visit and spoke with the Risk Management Specialist. This initial complaint was not logged as a grievance/complaint until 2/23/18 when the hospital received a written complaint of the same issues dated 2/18/18.
Per medical record review, the patient was seen in the ED for complaints related to gastro-intestinal concerns. The patient was not satisfied with their medical treatment during the visit.

Per review on 3/26/18, the hospital policy entitled: Patient Complaints and Grievances, approved 9/18/17, stated under Procedure:
6. The Quality and Risk Management Department (QMD) acknowledges receipt of the grievance in writing within 5 working days from the time of receipt in the Department. The written acknowledgement will include a description of the hospital's grievance and appeal process.
7. The manager/director of the responsible department investigates the grievance, documents investigation findings in SQSS, and drafts a response letter to the complainant, addressing each element of the grievance, investigative findings, and any action(s) or follow up taken or to be taken.
8. The manager/director collaborates with the Quality and Risk Management Department to finalize the grievance resolution letter. QMD then sends the resolution letter to the complaint within 30 days of the initial complaint.

During interview with the Director of Quality Assurance on 3/27/18 at 9:54 AM, the director confirmed that the risk management staff failed to follow the hospital's grievance policy/procedure. The Risk Management Specialist confirmed that they didn't send an acknowledgement letter to the complainant because they had no contact information. However, after viewing the letter of complaint again, they confirmed that the complaint's address and phone number were provided on the written grievance.
The Director of Quality Assurance also confirmed that the complainant had called the hospital 4 times asking about the grievance and leaving voice messages. The Risk Management Specialist confirmed that she was aware of the saved messages but had made no return call(s) to the complainant to review his concerns, per interview on morning of 3/27/18.

In summary, the hospital failed to provide a timely response to Patient #1's verbal and written grievance and failed to follow up on voice messages to the department; these failures violated the hospital's written policy/procedures for responding to complaints/grievances.