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Based on document review and interview, the facility failed to ensure a complainant was notified of a plan of action and provision of a written response to a grievance for 1 of 4 grievances reviewed. (Family member #1)

Findings include;

1. Facility policy titled "Customer Issue Resolution (Patient Grievance)" last reviewed/revised 5/2015 indicated the following: " ...III. Procedure E. A patient or family member and visitor may express to any hospital/PPG [Parkview Physician's Group] staff member a concern/complaint ...H. An attempt to reach the grievant within 48 hours of receipt of a concern/complaint will be made. The patient/family/visitor should be informed of a plan of action within 7 days of receipt of a concern/complaint. If the issue is unable to be resolved within this timeframe, then a timeframe will be established with the patient/family/visitor. A written response will be provided to the patient/family/visitor by the individual receiving the complaint unless delegated to a more appropriate individual ...."

2. A review of a grievance form titled "PATIENT RELATIONS WORKSHEET" related to patient #1 on 4/3/18 at 12:45 p.m., indicated a grievance was received on 3/13/18 at 1020 hours from family member #1. The following was indicated:
A note dated 3/16/18 at 0953 hours indicated the following: "HIPAA [Health Insurance Portability and Accountability Act] Compliance contacted to review HIPAA form as requested for correspondence to family member, [Family member #1]. Upon review of patient record, [Family member #1] is only listed on the emergency contact form for patient's last visit. This does not allow us to contact family listed after patient has been discharged. Upon review of the valid, HIPAA contact sheet, [Family member #1] is not listed. If [Family member #1] desires the correspondence, the necessary paperwork would need to be obtained from the court. [Family member #2] is listed on the HIPAA contact sheet."
A note dated 3/16/18 at 1059 hours indicated the following: "Per HIPAA officers, adv [advocate] office should not send out any correspondence at this time."
The grievance form lacked documentation of family member #1 being provided a plan of action or provision of a written response.

3. A review of an updated grievance form titled "PATIENT RELATIONS WORKSHEET" related to patient #1 on 4/4/18 at 5:58 p.m., indicated the grievance was received on 3/13/18 at 1020 hours. The following was indicated:
A note dated 4/3/18 at 1540 hours indicated the following: "I have attached my 3/16 correspondence why could not send correspondence to [Family member #1]. I believe that we discussed this via phone that we would need the next of kin to send correspondence. If I recall correctly, I mentioned that you may want to communicate this with the complaining [family member] as it was needed to provide correspondence to the appropriate individual."
A note dated 4/3/18 at 1548 hours indicated the following: "adv spoke w/ [with] [Family member#1]. [Family member #1] confirmed that her nickname is [Family member #2].
[He/she] is going to scan a copy of the pt's [patient's] death cert [certificate] that lists [him/her] as next of kin so that adv can send correspondence to [him/her].

4. During a telephone interview with staff A14 (Patient Relations) on 4/3/18 at 2:03 p.m., he/she verified no communication with complainant [Family member #1] since 3/13/18 due to consultation with legal and privacy officer concern regarding HIPAA since [Family member #1] was not listed on contact information for patient #1.

5. During an interview with staff A3 (Quality Assurance Specialist) on 4/4/18 at 5:55 p.m., he/she indicated the complainant (Family member #1) was contacted on 4/3/18 related to the grievance to confirm patient #1's contact information since there were three separate names listed in the patient's medical record.