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Based on record review, document review and staff interview it was determined the Director of Risk Management failed to follow the hospital's policy for filing a patient's grievance with documentation and follow-up for one (1) of two (2) autopsy complaints reviewed (patient #1). This failure has the potential to adversely impact all patients that wish to file a complaint or grievance against the facility.

Findings include:

1. Review of documents revealed an e-mail was sent on 9/2/16 to the hospital from the Medical Power of Attorney (MPOA) from the hospital's website requesting to be contacted in obtaining the results of her sister's autopsy that was performed on 9/4/15. The e-mail was sent to the Administrative Secretary of Pathology and she forwarded the e-mail to the Business Manager of Pathology.

2. An interview was conducted on 10/25/16 at 9:40 a.m. with the Office Administrator of Pathology. She entered the interview with a copy of the e-mail and when asked if she forwarded the e-mail to the Patient Advocate or filed an online complaint resolution report she stated, in part: "No, I forwarded it to four (4) of our transcriptionists and to our Business Manager. That is our routine."

3. Review of the policy titled, "Patient and Family Complaint and Grievance Mechanism", last reviewed 7/24/16, states, in part: "A complaint brought to the attention of hospital personnel in person or via the Internet...An online complaint resolution form should be completed within fourteen days...the complaint is considered resolved when the patient is satisfied with the actions taken on their behalf...If not satisfied the complaint becomes a grievance. A patient grievance is a written or verbal complaint...The patient advocate or designee will respond in writing to the complainant within seven (7) calendar days...If the resolution will take longer than seven (7) days the acknowledgement letter will inform the patient or the patient's representative that the hospital is still working to resolve the grievance."

3. Review of the hospital's call log of incoming and outgoing phone calls to the MPOA's telephone number from 9/2/16 through 9/21/16 revealed the MPOA called the hospital twenty (20) times and the hospital had two (2) outgoing phone calls on 9/16/16.

4. An interview was conducted on 10/24/16 at 3:00 p.m. with Patient Advocate #1 and she stated she remembered the complaint and that no letter was mailed to the MPOA because she felt it was a complaint and they do not send letters on complaints, only grievances.

5. An interview was conducted on 10/25/16 at 8:20 a.m. with Patient Advocate #1. When asked if the MPOA was satisfied with the outcome of the complaint, she stated, in part: "I thought she was because I thought the pathologist called and told her to come and pick up her results and now I realize she never got ahold of her so no, I don't believe she was satisfied and now I realize this should have been a grievance." When given the opportunity to review the call log, she stated, "I didn't know she called so many times." When asked if the MPOA had recieved the results of the autopsy as of today, she stated, "No, I will call her and send the results out today."

6. An interview was conducted on 10/25/16 at 9:45 a.m. with the Director of Neuropathology. When asked if she had contacted the patient's MPOA, she stated, in part: "I tried to call her once and I felt it was inappropriate to leave a voice mail about an autopsy. I did not know that she had never received her results until today."

7. An interview was conducted on 10/25/16 at 11:40 a.m. with the Director of Risk Management and she concurred with the above findings.

Based on document review and staff interview it was determined the hospital failed to follow their own policy to provide the complainant with a written response regarding the resolution of a complaint for one (1) of two (2) autopsy complaints reviewed (patient#1). This failure has the potential to negatively affect all patients from having the right to receive a written response as to the outcome of the hospital investigation.

Findings include:

1. Review of the policy titled, "Patient and Family Complaint and Grievance Mechanism", last reviewed 7/24/16, states, in part: "A complaint brought to the attention of hospital personnel in person or via the internet...is considered resolved when the patient is satisfied with the actions taken on their behalf...If not satisfied the complaint becomes a grievance. A patient grievance is a written or verbal complaint...The patient advocate or designee will respond in writing to the complainant within seven (7) calendar days...If the resolution will take longer than seven (7) days the acknowledgement letter will inform the patient or the patient's representative that the hospital is still working to resolve the grievance."

2. An interview was conducted on 10/24/16 at 3:00 p.m. with Patient Advocate #1 and she stated she remembered the complaint and that no letter was mailed to the MPOA because she felt it was a complaint and they do not send letters on complaints, only grievances.

3. An interview was conducted on 10/25/16 at 8:20 a.m. with Patient Advocate #1. When asked if the MPOA was satisfied with the outcome of the complaint, she stated, in part: "I thought she was because I thought the pathologist called and told her to come and pick up her results and now I realize she never got ahold of her so no, I don't believe she was satisfied and now I realize this should have been a grievance."

4. An interview was conducted on 10/25/16 at 11:40 a.m. with the Director of Risk Management and she concurred with the above findings.

Based on record review and hospital expectations it was determined the Director of Medical Records failed to release autopsy results in one (1) of two (2) autopsy complaints reviewed (patient #1). This failure has the potential to adversely impact all patients or representatives that request medical records in a timely manner.

Findings include:

1. Review of the medical record for patient #1 revealed an autopsy was requested on 9/4/15. At the time of the request, autopsy consents were signed by the patient's medical power of attorney (MPOA) and a release of information was also signed.

2. Review of an e-mail from the MPOA to the hospital on 9/2/16 revealed the MPOA requested information on her sister's autopsy and it was determined the e-mail was not forwarded to the proper department of the hospital.

3. Review of the hospital's call log of incoming and outgoing phone calls to the MPOA's telephone number from 9/2/16 through 9/21/16 revealed the MPOA called the hospital twenty (20) times. The hospital had two (2) outgoing phone calls on 9/16/16 and no other attempt to contact the MPOA could be verified.

4. An interview was conducted on 10/26/16 at 10:15 a.m. with Patient Advocate #1. When asked if the hospital had a policy on the release of autopsy results, she was unsure and contacted the hospital's medical record department. When asked if the MPOA had received her autopsy results, she stated, in part: "She should get them today. I overnighted them with FedEx yesterday when I realized she had never received the results."

5. Review of an e-mail sent 10/26/16 at 10:27 a.m. from the Medical Records Department revealed, in part: "It is standard procedure and not a written policy...when an autopsy is completed, the completed report is sent via interoffice mail to our office with a letter noting it is completed and ready for scanning...then the autopsy is sent to the consenting person...it was never scanned into the optical imaging system or mailed to the family member who consented to the autopsy."

6. An interview was conducted on 10/26/16 at 1:15 p.m. with the Manager of Risk Management and she concurred with the above findings.

Based on record review and hospital expectations it was determined the Director of Medical Records failed to release autopsy results in one (1) of two (2) autopsy complaints reviewed (patient #1). This failure has the potential to adversely impact all patients or representatives that request medical records by not receiving the records in a timely manner or to be incompletely and inaccurately documented.

Findings include:

1. Review of the medical record for patient #1 revealed an autopsy was requested on 9/4/15. At the time of the request, autopsy consents were signed by the patient's medical power of attorney (MPOA) and a release of information was also signed.

2. Review of an e-mail from the MPOA to the hospital on 9/2/16 revealed the MPOA requested information on her sister's autopsy and it was determined the e-mail was not forwarded to the proper department of the hospital.

3. Review of the hospital's call log of incoming and outgoing phone calls to the MPOA's telephone number from 9/2/16 through 9/21/16 revealed the MPOA called the hospital twenty (20) times. The hospital had two (2) outgoing phone calls on 9/16/16 and no other attempt to contact the MPOA could be verified.

4. An interview was conducted on 10/26/16 at 10:15 a.m. with Patient Advocate #1. When asked if the hospital had a policy on release of autopsy results, she was unsure and contacted the hospital's medical record department.

5. Review of an e-mail sent 10/26/16 at 10:27 a.m. from the Medical Records Department revealed, in part: "It is standard procedure and not a written policy...when an autopsy is completed, the completed report is sent via interoffice mail to our office with a letter noting it is completed and ready for scanning...then the autopsy is sent to the consenting person...it was never scanned into the optical imaging system or mailed to the family member who consented to the autopsy."

6. An interview was conducted on 10/26/16 at 1:15 p.m. with the Manager of Risk Management and she concurred with the above findings.