HospitalInspections.org

Based on record review and interview the hospital failed to follow their internal policy and procedure for grievances by failing to conduct a timely investigation of a written grievance on behalf of a patient concerning quality of care for 1 of 1 patients who informed hospital staff of a grievance in a total sample of 20 patients (#10). Findings:

Review of the Hospital's Policy & Procedure titled Patient Complaint/Grievance reflected the hospital would provide a process to review, investigate, and resolve a patient's / patient representative's complaint / grievance within a reasonable time frame.

Further review of the policy reflected the Hospital's Quality Improvement Committee would ensure the patient was provided written notice of its decision regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance. Documentation in the policy and procedure reflected that the patient would receive a receipt to confirm a notice had been received even if a decision and/or resolution regarding a complaint/grievance had not been determined within the 7 day limit.

Review of the Hospital's Patient Grievance/Complaint Log revealed documentation that patient #10 had filed a written complaint to the hospital concerning quality of care. Review of the log revealed the hospital received the written complaint on 12/15/09. There was no evidence in the hospital records to reflect the hospital had responded to the patient's complaint as of 01/14/10, a total of 30 days after receipt of the complaint.

Interview on 01/13/10 at 2:00 p.m. with S8 Quality Management Director, confirmed the hospital had received a written complaint from patient #10 on 12/15/09, but the hospital had not responded to the patient's written complaint within a reasonable time frame as required per Hospital's Policy & Procedure. S8 stated the hospital had started the investigation of the complaint but had failed to inform the complainant.