HospitalInspections.org

A. Based on review of Hospital policy, review of Hospital complaint log Feedback Report, and staff interview, it was determined that in 1 of 1 (Pt #1) clinical record reviewed, the Hospital failed to ensure all patient complaints were initiated and investigated in a timely manner per policy.

Findings include:

1. Hospital policy entitled, "Patient/Patient Representative Grievance Management Process," reviewed on survey date 4/8/10 at 10:00 AM required, "...C. Grievances must be managed utilizing the following steps: 1. Address immediately grievances that may harm the patient or have serious implications...3. Provide initial contact with patient/patient representative within seven (7) days of receipt of written complaint...6. Conduct investigation in a timely manner. Contact the following departments for assistance as applicable:..Concierge Services..."

2. The Hospital's Complaint Feedback Report dated 3/29/10 was reviewed on survey date 4/8/10 at 11:00 AM. The Report indicated that Pt #1's complaint was received by administration on 3/11/10, however Pt #1's complaint was not forwarded to the Concierge service, for investigation until 3/22/10 (11 days), and to the Nurse Manager until 3/29/10 (another 7 days).

3. The findings were verified by the Hospital's Clinical Director of In-Patient Nursing and The Hospital's Senior Director of Quality during an interview on survey date 4/8/10 at 12:30 PM.