HospitalInspections.org

Based on review of documents, policies, and staff interview, the hospital's administrative staff failed to forward all patient grievances to the Patient Guest and Relations Coordinator according to policy. The Chief Nursing Officer identified 2 of 2 patient grievances forwarded by administrative staff directly to the in-house attorney (Patient #1 and #2).

The Patient and Relations Coordinator receiving approximately 57 grievances monthly. The Chief Compliance Officer reported approximately one grievance every three months was forwarded directly to the in-house attorney for review.

Findings include:

1. During entrance on 1/27/14 at 11:15 AM, the survey team requested documentation of patient and/or family grievances and complaints for the past six months.

At 2:30 PM, the Chief Nursing Officer (CNO) presented a list of grievances and complaints for the past six months. The list lacked evidence of grievances submitted on behalf of Patients #1 and #2.

2. During interviews on 1/27/14 at 4:30 PM and 1/28/14 at 10:10 AM, the CNO said the Patient and Relations Coordinator was responsible for oversight of all grievances. However, the CNO identified there were two grievances not forwarded to the Patient Guest and Relations Coordinator. The CNO said the two grievances were sent to administrative offices, were not entered into the grievance system, and were not brought to the attention of the Patient Guest and Relations Coordinator, as a normal grievance, due to their mode of arrival. The two grievances related complaints made on behalf of Patient #1 and Patient #2 by attorneys.

3. Review of the hospital's policy, "Complaints and Grievances, Receiving and Responding" with a revision date of 11/11, revealed the following in part, "Patients and families have the right to ask questions and voice...concerns related to the quality of care and services received...this information will be communicated within a copy of the Patient Rights and Responsibilities handbook...the Patient and Guest Relations Coordinator will be considered the clearinghouse for all complaints and grievances."

Review of the hospital's policy, "Patient Rights and Responsibilities" with a revision date of 9/11, revealed the following in part, ..."All patients or the patient's surrogate decision maker will at their first registration for services...and at every admission, be informed in writing of their patient rights and responsibilities including their rights to voice a complaint or grievance. This information will be contained in the Patient Handbook."

Review of the hospital's "Patient Handbook" dated 1/12, revealed the following in part, ..."A grievance can be filed directly with the Broadlawns Medical Center Patient Advocate. The Patient Advocate will investigate your concerns, take corrective action if possible and communicated the results of the investigation to you."

Review of document titled "Patient Complaint Meeting dated 1/24/14 and presented to the survey team by the CNO at 4:30 PM, revealed the following in part, ..."the purpose of the meeting was to discuss the process for follow-up of logging of patient complaints which have not been reported to [Patient Guest Relations Coordinator]...the Patient and Guest Relations Coordinator is considered the clearinghouse for all complaints and grievances and works to resolve the issues...complaints from outside entities...are received and reviewed by the Risk Management Team and then routed to the Patient Advocate...the Meditech Quality Management Complaint System will be audited quarterly by the Executive Coordinator...to assure complaints from...outside entities are documented in the Quality Management Complaint Module."

4. During an interview on 1/28/14 from 3:40 PM, the Patient Guest Relations Coordinator said her department was a "clearinghouse" for all patient complaints and grievances. She denied receiving or reviewing the grievances regarding Patient #1 and #2 and acknowledged they were not routed to her department. During a follow up interview at 4:10 PM, after reviewing the grievances submitted on behalf of Patient #1 and #2 with the Chief Compliance Officer, the Patient Guest Relations Coordinator said that they decided that all grievances will be routed to her department no matter the mode of arrival to the hospital.

During a follow up interview on 1/29/14 at 1:50 PM, the CNO acknowledged the prior Complaints and Grievances, Receiving and Responding policy failed to identify the processes for grievances that were received and were not routed to the Patient and Guest Relations Coordinator for logging and monitoring purposes. The CNO said the hospital revised the Complaints and Grievances policy "today" (on 1/29/14) to include instructions for routing grievances regardless of how they are received to the Patient and Guest Relations Coordinator."

5. Review of the hospital's revised policy , "Complaints and Grievances, Receiving and Responding" with a revision date 1/2014, revealed the following in part, ..." a copy of any grievances that is initially sent to Executive Offices...or filed with a third party...will be forwarded to the patient and guest relations coordinator."