HospitalInspections.org

Based on interviews, and document review the facility failed to have a consistent procedure to ensure patients could register complaints with the facility and complaints were investigated and resolved timely. Further, the facility failed to inform patients how to contact the Department of Public Health and Environment to register complaints for 2 of 6 grievances reviewed (Patients #6 and #11).

This failure resulted in patient's complaints not being processed, reviewed, and resolved in a timely, consistent manner.

FINDING

POLICY

According to Patient Complaint, Discrimination and Grievance (approved 09/06/13) patients are informed of their right to file a Complaint with the State Health Department, regardless of whether they first use the Grievance process, as well as the telephone number and address of the State Health Department. Patients are informed of their right to seek review by the Quality Improvement Organization for quality of care issues, coverage decisions and to appeal a premature discharge. A Complainant has the right to file an appeal and will be informed about the appeal process. Within ten (10) business days of receiving the request for Grievance Committee review, investigate the complaint and report findings to the complainant. Inform the complainant that, upon request, the complaint and findings will be reported to the Colorado Department of the Public Health and Environment, and that he/she may register a complaint directly with the Department.

1. The facility did not follow a policy or have a consistent procedure to file a complaint when a patient reported concerns.

a) A review of the complaint/grievance log provided by the facility revealed 6 grievances were reported in the last 6 months. Further review of the individual grievances revealed 2 of 6 to be outside the timeframe outlined in facility policy.

Patient #11 notified the facility of his/her complaint 02/29/16. On 03/09/16, a letter stating the grievance required further investigation was sent to Patient #11. Forty-five business days later a final letter with the results of the grievance was sent on 05/11/16.

On 05/13/16 the facility was notified of Patient #6's grievance. A letter sent on 05/20/16 stated the grievance required further investigation. On 06/03/16, 14 days after the grievance notification, a second letter stated the grievance required further investigation. During an interview, on 07/12/16 at 2:17 p.m., Patient Relations Consultant (PRC) #1 confirmed a final letter with investigation results of the grievance had not been sent to Patient #6. Forty business days had lapsed since the initial grievance notification.

b) During an interview, on 07/13/16 at 8:46 a.m., Social Worker #2 stated the current process for filing a complaint was to e-mail the department manager. S/he was unaware of how the complaint or grievance was investigated or completed. S/he reported no recent education with regards to this topic.

c) During an interview, on 07/13/16 10:30 a.m., Registered Nurse (RN) Manager #5 stated s/he had no recollection of any education regarding the grievance process.

d) During an interview with the Chief Nursing Officer (CNO) #3, on 07/13/16 1:00 p.m., s/he stated the Patient Complaint, Discrimination and Grievance policy was the facility's current policy for complaints and grievances. S/he stated s/he expected staff to follow facility policy. S/he confirmed the grievances for Patient's #6 and #11 were out of the acceptable date range for response time.

e) During an interview with PRC #1, on 07/13/16 at 9:35 a.m., s/he stated the grievance letter writing process was stressed. S/he stated the Patient Service Center for the facility had identified this as a concern and was currently in the process to correct this; however, no documentation dated before the survey could be provided.

f) During an interview, on 07/13/16 at 1:50 p.m., Regulatory Consultant #4 stated the Patient Relations Service Center for the facility could not explain why the current policy was overdue for a review and was not updated to reflect the facility's current process.

2. The facility did not inform patients of their right to file a complaint with the State Health Department.

a) During a tour of the facility on 07/12/16 at 11:45 a.m., it was noted the front registration area of the facility did not have information on filing a complaint with Colorado Department of Public Health and Environment. During the same tour a sign in the Emergency Room listed the Colorado Department of Public Health and Environment as a resource to report any complaints or grievances; however, no contact information was provided. This was in contrast to facility policy.

b) A review of the Patient & Visitor Information packet revealed no mention of the Colorado Department of Public Health and Environment and how to contact the Department with a complaint.

c) During an interview with CNO #3, on 07/13/16 at 1:00 p.m., s/he stated there was no information given to patients that explained how to file a complaint with the Colorado Department of Public Health and Environment.

d) During an interview with Regulatory Consultant #4, on 07/12/16 at 3:15 p.m., s/he stated there were no signs in the facility that directed patients how to contact the Colorado Department of Public Health and Environment and file a complaint.