HospitalInspections.org

Based on review of hospital policies and procedures, the hospital's complaint/grievance log, and selected grievances, the hospital failed to establish and follow a process for prompt resolution of patient grievances. This occurred in two of four complaints/grievances (Records #8 and 9 of Records #6, 7, 8, and 9) reviewed.

Findings:

1. The hospital's policy, Opportunities for Improvement (OFI), correctly defined the difference between complaints and grievances and defined grievances as any concern that was not resolved at the time with the staff present. Staff C stated the program used to generate the log only let them log the entries as complaints if they were resolved in-house while the patient was still there and/or if no letter was sent.

2. The hospital's grievance policy, OFI, did not ensure a prompt resolution to the patient's or patient's representative's grievance. The OFI policy allowed 45 days for a written response to be sent to the patient/patient's representative. Medicare guidelines recommend, on an average, the complaint should be resolved and a written notice of the investigative process be sent within seven (7) days.

3. The complaint/grievance log listed all entries recorded as complaints. All entries showed the complaint/grievance was resolved/closed. Multiple entries showed resolution dates as a different date than the date the concern was expressed. Four of these complaints/grievances were selected for review.

4. Grievance #8 - the grievance was filed on 07/13/2011 and closed on 07/15/2011 by one of the patient's representatives. Documentation reflected staff talked with another patient representative and a decision was made to not sent a written notice to the patient. The report did not demonstrate a written notice of the investigation with the required elements was sent to the complainant/patient's representative who filed the complaint. Staff C stated the hospital only sent letters to the patients and not the patient's representatives who filed the complaints.

5. Grievance #9 - the grievance was filed on 09/26/2011 by the patient's representative/parent. Although the complaint/grievance log documented the grievance was resolved on 10/03/2011, Staff C stated the grievance was ongoing and was not resolved. The report documented a closed date of 10/03/2011 for the complaint and did not demonstrate a written notice have been sent with the required information. Staff C stated she did not know why the log showed the grievance had been resolved. The grievance process did not have an accurate tracking mechanism.