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Based on the review of medical records, documentation, and interviews with hospital staff, it was determined that in one of one record (#3) the hospital failed to provide the patient or patient's representative with a written notice of the receipt of, and investigation of a patient/family grievance according to time frames identified in the hospital policy and procedure and consistent with applicable State law.

Findings:

Review of record #3 revealed that the patient had an Emergency Department (ED) visit 2/22/11. The record reflected that patient #3 was brought to the ED by ambulance with an intravenous (IV) access site to the left forearm. The record further reflected that the IV site became painful, and was replaced by an RN.

Documentation was reviewed and an interview was conducted 4/12/11 at 1700 hours with the Director of Public Relations and revealed that he/she had received a complaint by telephone on 2/23/11. The content of the complaint identified circumstances related to Patient #3's IV on 2/22/11. The Director of Public Relations revealed that he/she forwarded the complaint information to the ED Manager and was unaware of a written response provided to the complainant thereafter.

The following policy was reviewed: "GOOD SHEPHERD HEALTH CARE SYSTEM-WIDE POLICIES AND PROCEDURES Performance Improvement/Risk Management SUBJECT: Patient Complaints", revised date: 7/2010. The policy and procedure directed the following: "The staff member receiving the complaint will begin by recording the salient information in Policy 801c-Customer Service Opportunity" and "The complaint will then be forwarded to the appropriate department manager for resolution. If the complaint cannot be resolved within seven business days, the manager shall send a written response to the complainant or the complainant's representative to acknowledge receipt of the complaint and that action has been initiated to resolve the issue (See Policy 801b-Acknowledgement Letter)" and "If the appropriate department manager cannot reach a complaint resolution satisfactory to the complainant, the manager shall arrange a meeting among the Senior Vice President, the manager, and the complainant to further attempt to achieve a resolution. If a resolution is not reached, the matter shall be forwarded to the President for final resolution. The President may or may not meet with the complainant at the President's discretion."

An interview conducted 4/13/11 at approximately 0930 hours with the ED Manager revealed that "within a couple weeks" of receiving the complaint he/she reviewed patient #3's record, and hospital staff had conducted an extensive phone communication with the complainant "a few days to a week" thereafter. The ED Manager verified that after the phone communication, the complainant remained dissatisfied with the outcome of the complaint.

An interview conducted 4/13/11 at 1100 hours with the Vice President of Nursing Services and the ED Manager revealed that the hospital was in the process of transitioning to an on-line complaint/grievance process and that the hospital failed to provide a written response to patient #3's grievance in writing and within the timeframes identified in the hospital policies and procedures.

An interview conducted 4/13/11 at 1310 hours with the Director of Public Relations revealed that he/she considered the complaint to be resolved because the complainant remained dissatisfied even after several phone communications and an email to hospital staff, and that the hospital staff had exhausted all reasonable efforts to resolve the complaint to the complainant's satisfaction.

These findings also reflect non-compliance with the following Oregon Administrative Rules (OAR) for Hospitals: OAR 333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).