HospitalInspections.org

Based on policy/procedure review, staff interview, and review of other documents, the hospital failed to complete and send written communication to the complainant within stated time frames for 5 of 22 grievances.

Findings include:

1. The hospital policy/procedure titled "Patient Complaint and Grievance Policy" was reviewed on June 16, 2010. The policy/procedure states "PROCEDURE, 5. Grievance resolution and communication, c. Complex investigations. *When more than 7 days are needed to resolve the complaint/grievance, contact should be made with the patient/representative or complainant about the progress of the grievance resolution., *Resolution of the grievance is a top priority and should occur as soon as possible, our goal is to resolve issues rapidly - preferably within 7 days of receipt but standardly within 30 days of receipt., *In certain complex situations, such as those involving peer review, more than 30 days may be required to resolve the issue. In that case the responsible manager will send a letter to the patient/representative indicating he/she is working on the resolution. The letter will specify that the assigned manager will follow up with another written response in a specific time period regarding resolution of the complaint."

2. Hospital grievances for the last 3 months were reviewed on June 16, 2010. Twenty-two grievances were reviewed. Five of the 22 grievances had not been resolved within 30 days nor was there a written response sent to the patients/representatives of why and/or when resolutions were expected.

3. A risk manager was interviewed on June 16, 2010. The risk manager stated she was responsible for the resolution of the 5 grievances. She stated she had not followed up on the resolutions and no written communication had been sent to the patients/representatives.