HospitalInspections.org

Based on record review, policy review and interview, the facility failed to establish a process for prompt resolution of grievances. Findings include:

1) Review of the facilities online complaint log on 01/20/2010 revealed that 4 of 5 ( patient's #1, #2, #3 and #4) had open grievances against the facility and had not received a written response for resolution of the grievance. Open grievances that had not yet received a written response dated from 08/08/09 to 12/29/09.

2) Review of the facilities policy reveal no definitive time frames for resolution of a grievance. Policy name: "Concern and Grievance management" under heading "V. Procedure D. All verbal or written concerns that meet the definition of a grievance will be responded to in writing, unless the complainant specifically states that they do not want a written response (such request should be documented). Within limits of legal protections afforded to healthcare organizations, the written response will include notice of the hospital's decision, the name of the hospital contact person, the steps taken on behalf of the patient to investigate the concern or grievance, the results of the grievance process, reference to the MDCH Complaint process, and the date of completion."

3) Per Risk Manager on 01/20/10 at 12:40 PM, it is the responsibility of their department to send out the written responses regarding grievances.

4) It was confirmed by Director, Patient Relations & Risk management on 01/20/10 at 5 PM that patient's #1, #2, #3 and #4 had not received written responses concerning their grievances.