HospitalInspections.org

Based on document review and interview, the facility failed to assure a written notice to a patient of its decision in the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings:

1. Review of hospital policy ADM 1.34, Patient/Parent Rights and Responsibilities, Complaint and Grievance Process, approval/effective date of June 2000 with revision dates of May 2003, February 2004, May 2005, and May 2008 on 02/05/10 at approximately 12:10 PM indicated:
a. Page 3 of 5, Patient Grievance Process, G., "The patient will receive a written response regarding the resolution of the patient complaint. This written response will include:
? the name of the hospital contact person;
? the steps taken on behalf of the patient to investigate the grievance;
? the results of the grievance process except that information protected by peer review;
? and the date of completion."

2. Review of hospital letter to complainant dated 11/13/09 and signed by #S5 indicated lack of documentation of the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

3. Interview with #S8 on 02/05/10 at approximately 12:10 PM indicated that when he/she had taken the position of director of risk management, August 2009, staff thought resolution was when patient advocate responsibilities were completed. It could not be determined if each complainant received written notice due to lack of feedback by person given the referral and no type of logging system. #S8 confirmed the true intent of the Regulation had not been met in the letter to complainant dated 11/13/09.