HospitalInspections.org

Based on record review and interview, the hospital failed to provide the patient with a written notice of its response to and resolution of a grievance filed by 1 of 1 patients (#1) reviewed.
Findings:

Review of the hospital's Policy and Procedure for Customer Comments, Complaints and Grievances (revised 07/24) revealed, in part...
Written Notice - Administrative representatives will have the final responsibility for the resolution of the grievance, as well as provision of wtitten notice to the patient.
The complainant will be provided with a copy of the written response. The response will contain the required information outlined in the Conditions of Participation.
Further review of the policy revealed no clear timeline for the written response to the complainant when the grievance has been resolved.

Review of the written grievance filed by Patient #1 dated 07/24/2025 at 08:26am revealed she requested a written response within 14 days.
Review of the grievance investigation revealed the investigation was completed on 07/28/2025.
Further review revealed no documented evidence that a written response had been sent to Patient #1 as of 08/11/2025.

On 08/11/2025 at 3:30pm, an interview with S1Quality Director confirmed that no written notice of the grievance resolution had been sent to Patient #1. She further confirmed that the policy needed revisions for clarification of written notice timeframes, but confirmed that a written response should have been sent within 7 days of the completion of the investigation.