HospitalInspections.org

Based upon review of 1 of 6 medical records (#5), policies and procedures, patient complaints/grievances and administrative and staff interviews, the hospital failed to provide a written notices to each patient or their representative as related to the resolution of the complaint or grievance. This was evidenced by the hospital failing to provide patient #5 a written response to a complaint that was provided in writing and delivered by certified letter to the hospital in July 2010. Findings:

Review of the hospital's policy for the Grievance Process revealed a policy titled "Procedure for Comments, Complaints and Grievances" revealed patient complaints/grievances were divided into three levels. Level I was identified as "Department Manager or supervisor handles the comment with immediate and prompt resolution of the complaint." Level II "The Department Manager resolves the issue promptly with assistance of appropriate personnel." and Level III "The comment is considered a grievance and enters the grievance process. These comments should be reviewed immediately and concluded. The documentation of actions taken should take on longer than 7 days..."

Review of the Level I through Level III grievances filed for the past 8 months revealed on July 14, 2010, patient #5 sent a written complaint to the hospital via certified mail. This complaint was related to two separate incidents that occurred during the patient's hospitalizations in December 2009 and January 2010. The complaints were in relation to an attempted theft of a purse and the hospital's security personnel.

Interview with the hospital administrator S1 on 08/23/10, 1:30 PM, revealed while patient #5 was in the hospital in December 2009, she complained that a nursing aide tried to steal her purse. S1 stated he investigated the complaint and after telephoning the patient with the results of his investigation, he assumed the complaint was resolved. S1 further stated patient #5 was re-admitted to the hospital on 01/27/10 and discharged on 01/29/10. Upon returning home,. S1 stated patient #5 called the hospital and alleged that the hospitals's security followed her home in their car. S1 further stated at the time of the second complaint, he was away from the hospital and had "thought it went through the grievance process." On July 14, 2010, S1 stated that they had received a written complaint via certified mail from patient #5 regarding the same issues she had made in her complaints in December 2009 and January 210.. When asked if the complaint had been investigated and the patient provided a response, S1 stated "no".

The hospital failed to ensure the complaints that were provided in writing were addressed through the grievance process and the patient was provided a written response that included the hospital contact person, the steps taken to investigate the grievance, the results of the investigation and the date of completion.