HospitalInspections.org

INTAKE #34830

Based on facility policy, record review and interview, it was determined the facility failed to provide the patient/family with written notification of the facility's investigation into the grievance, steps to resolve the grievance, including the contact representative from the hospital for 1 of 2 (Patient #4) grievances reviewed.

The findings included:
1. Review of the facility policy, "COMPLAINT AND GRIEVANCE RESOLUTION:PATIENT AND FAMILY" revealed, "...PURPOSE: To establish a process for timely referral, prompt review, investigation and resolution of patient grievances and complaints...DEFINITIONS...A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further actions for resolution...C. Grievance Resolution Process 1. Grievances may be received written, verbally, via electronic mail or facsimile, or by telephone to any department...2. Upon receipt of a grievance, Director of Quality/Risk shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance with exception of complaints that endanger the patient...4. Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper systematic problems...5. In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion...D. Tracking, Trending, and Analysis of Data 1. A grievance /complaint log within the [name of system] will be maintained by the Director of Quality/Risk. The documentation in the log will include date of complaint, location, summary of issue, how the issue was addressed, date resolved and response to complainant, and the individual responding to the grievance...2. Documentation of the resolution process will include:...Pertinent investigational information, Resolution/follow-up including written response for grievances, Signature of person addressing complaint/grievance..."

2. Review of the grievance for patient #4 revealed a " Physician Related" complaint. The description of events documented, "PT"S [patient's] MOTHER CALLED VERY UPSET WITH SON'S TREATMENT AND DISCHARGE FORM ED TODAY FOLLOWING A MVA [motor vehicle accident]. AT TIME OF CALL PATIENT WAS IN ROUTE TO [another hospital] SEEKING FURTHER TX . THE COMPLAINT WAS DIRECTED MAINLY TO [physician]. PATIENT'S MOTHER REPORTED THAT [physician] SPENT LESS THAN 3 MIN [minutes] WITH PATIENT, DID NOT COMPLETELY ASSESS HIM AND SENT HIM HOME WITH AN ORDER TO FOLLOW UP WITH AN EYE DOCTOR. THE PATIENT HAS A HISTORY OF MULTIPLE CONCUSSIONS AND WAS EXPERIENCING BLURRED VISION AND UNRELENTING HEADACHE, NAUSEA AND AT TIME OF CALL INCREASING LUQ [left upper quadrant] PAIN." The follow up section documented that the Nursing Supervisor was notified on 4/22/14 at 1840. There was nothing documented in the section "...PT/FAMILY NOTIFIED, DATE, TIME, METHOD OF NOTIFICATION, NOTIFIED BY..." The "REVIEWED BY MANAGER " section documented "...WILL NEED TO REVIEW RECORD AND SEND FOR REVIEW..."
The grievance did not document an investigation into the allegations, follow-up and written notification to the patient/family regarding resolution.

In an interview in the Quality Conference room on 10/20/14 at 11:50 AM, the Quality Standards Coordinator verified the incident would be considered a grievance because it did not fit the policy definition of a complaint. At 11:57 AM, the Quality Standards Coordinator stated she was unable to locate any additional documentation regarding follow-up/written notification to the patient.