HospitalInspections.org

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Based on document review and interview, in two (2) of four (4) documents reviewed, staff did not complete grievance investigations timely or provide grievance resolutions to patients or representatives as per facility policy.

Findings:

The facility Policy and Procedure titled "Patients' Rights - Patient Grievances" last reviewed June 2016, contained the following statements: "A written response will be sent to the patient or representative within 30 days from the date the grievance was received .... If the investigation takes longer than the anticipated 30 days, the patient / representative will be informed of the status of the investigation and an anticipated resolution date ... once the response is received from the responsible party, a response to the patient or representative is drafted. When the response is sent to the patient or representative, the case is closed."

The Grievance File for Patient #1 revealed that the complainant submitted a written grievance to the facility on 11/12/18.

On 11/20/18 and 11/26/18, the complainant made follow-up phone calls to the facility requesting a response to her grievance. Staff B (Emergency Department Medical Director) was notified of the complainant's inquiry on 11/20/18. On 11/26/18, both Staff B and Staff E (Chief Medical Officer) were notified. No evidence was found that an investigation had been initiated, performed, or completed.

On 12/10/18 and 01/24/19, the Patient Advocate (PA) requested an update of the investigation from Staff B in an attempt to close the case. As of 01/30/19, seventy-nine (79) days after the initial grievance was submitted, no documented evidence that an investigation had been completed was found.

During interview of Staff A (Assistant Vice President of Quality and Risk Management) on 01/31/19 at 8:30AM, Staff A acknowledged that repeated attempts for staff to respond to the complaint should have been escalated, and that updates regarding the investigation and a closure letter should have been sent to the complainant.

The Grievance File for Patient #12 revealed that the complainant filed a grievance with the facility on 11/07/18. As of 01/30/19, eighty-four (84) days after the grievance was submitted, no documented evidence that a closure letter had been sent to the complainant was found.

During interview of Staff A on 01/31/19 at 8:30AM, Staff A acknowledged a closure letter should have been sent to the complainant regarding the outcome of the investigation.