HospitalInspections.org

Based on record review and interview the facility failed to follow the facility's Grievance Process when it could not provide evidence of sending written responses to complainant's/patient's grievances.

Findings Include:

Review of the facility facility's Policy: Patient/Family Complaint and Grievance Process (dated 3/2014) reflected: " ...To establish procedures in which conflict/complaint/ grievances are handled in an appropriate and timely manner ..." " ...definitions Grievance - A patient care complaint not resolved promptly by staff available ..." "Policy ...To establish a process for prompt resolution of patient complaints/grievances ..." " ...The Patient Liaison or other designee from the Resolution Committee will provide to the patient/complainant written notice of its decision regarding the substance of each grievance that contains the name of a hospital contact, steps taken to investigate, and the date of completions. This notice will be sent to the complainant/patient as soon as possible after a determination has been made ...."

Review of the Patient Grievance Reports from 4/2015 to 3/2016 (rolling 12 months) reflected in part "... (2) Patient Care, (2) staff communication, (6) Staff treatment, (3) staff attitude, (2) staff communication and (1) hygiene Grievances...." The facility could not provide evidence of a written resolution communication to the complainants.

On 5/2/16 at 4:00 p.m. in the facility conference room, Staff #15, Quality Manager confirmed the finding.