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Based on interviews and record review, the hospital grievance process did not include a time frame for the provision of a written response.

In an interview at 10:15 AM on 01/12/11 with the Director of Customer Service (Personnel # 4), she was asked what time frames the hospital used to A: review a grievance, and B: provide a written response. She said that they review and and attempt to resolve a grievance within 7 days, but they do not have a time frame for the provision of a written response regarding the hospital's final determination of the grievance.

The hospital's "Complaints" policy, last revised 05/04/06, noted the following regarding:

A: the time frame for review of a grievance:
-"The hospital will review, investigate and attempt to resolve each patient's grievance within a reasonable time frame, usually seven (7) days."

B: the provision of a written response:
-"If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) days, the patient or the patient's representative will be advised of when to expect a response."
-"A written response of the hospitals determination regarding the grievance will be provided to the patient or the patient's representative."

In an interview at 3:25 PM on 01/13/11 with the Vice President of Quality/Physician Relations (Personnel # 2), she agreed that the hospital's "Complaints" policy and their grievance process did not include a time frame for providing a written response to the patient with the hospital's final determination of the grievance.

Based on interviews and record review, the hospital had not followed their grievance process, nor regulatory requirements, in that, they had not provided the patient (Patient # 1), with an initial response within their 7 day timeframe, nor had they provided a written notice of its decision that contained the following components: A. the steps taken to investigate the grievance, B. the name of the hospital contact person, C. the results of the grievance process, or D. the date of completion.

In an interview at 10:15 AM on 01/12/11 with the Director of Customer Service (Personnel # 4), she was asked to describe their grievance process. She said that her job is to take in all complaints and grievances, to complete a "Complaint Information Form," and to refer those complaints to department managers, who are responsible for following and providing written responses from their own areas. When asked if the complainant (Patient # 1), had filed a complaint or grievance while she was hospitalized from 03/06/09 to 03/07/09, she said "no," but that she had received a telephone call from her on 08/10/09, and she had completed a Complaint Information Form, #304, which she had referred out to the department manager (Personnel #8) and to the Director of Security (Personnel # 5) for their review and follow-up.
Personnel #4 said that she does not keep a complaint log, and even though she had spoken to the complainant several times by telephone, that she had not documented the dates and times of those interactions. She said that the department managers are responsible for sending written responses to the complainants, and in this case, she had helped to coordinate different areas associated with this one complaint.

Review of the hospital's written letter from Personnel # 4 to the complainant (Patient # 1), dated 08/20/09, stated that "this letter is in response to the concerns that you shared with me, on August 10, 2009, regarding your care provided here..., on March 6, 2009. The information you provided was immediately reported, an investigation was conducted, and all information was reviewed for process improvement opportunities. I want to thank you for sharing your concerns with..."

Personnel # 4 verified that she had sent the above written response letter to Patient # 1 dated 08/20/09, after receiving the initial telephone grievance on 08/10/09, 10 days earlier. She said that this was the hospital's first response, and agreed that it had not been sent within their policy time frame of 7 days. She also agreed that this letter had not included: A. the steps taken to investigate the grievance, B. the name of the hospital contact person, C. the results of the grievance process, or D. the date of completion. She stated that, although this letter said to call her for any additional questions, that she was not the designated hospital contact person for this complainant, as that would be the role of the department manager.


The hospital "Complaints" policy, last revised 05/04/06, noted the following process to resolve patient grievances:
1. "The hospital will review, investigate and attempt to resolve each patient's grievance within a reasonable time frame, usually seven (7) days."
2. "If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) days, the patient or the patient's representative will be advised of when to expect a response."
3."A written response of the hospitals determination regarding the grievance will be provided to the patient or the patient's representative. The written response should contain the name of a 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. Department managers are responsible for providing the written response for grievances received which pertain to their areas."

In an interview at 1:10 PM on 01/13/11 with the Medical/Surgical department manager (Personnel # 8), when asked if she had known about this grievance at the time it had happened on 03/07/09, she said "no," that it had not been reported to her at that time, even though Patient # 1's verbal complaints to the nurse and two house supervisors rose to the level of a grievance on that date. When asked for a record of her department's Grievance Log, she provided the log for March 2009, which did not contain this grievance. She verified that she had not sent a final written response to the complainant, as required by hospital policy..

In an interview at 10:45 AM on 01/13/11 with the Director of Security (Personnel # 5), he confirmed that he had sent a letter to Patient # 1 in response to her request for a copy of the video taken outside of the emergency department the evening of 03/07/09, in which he stated that "the videos are the property of the hospital, and can only be acquired if ...subpoenaed by a Magistrate." Personnel # 5 confirmed that his written response to Patient # 1 did not include: A. the steps taken to investigate the grievance, B. the name of the hospital contact person, C. the results of the grievance process, or D. the date of completion.

In an interview at 3:25 PM on 01/13/11 with the Vice President of Quality/Physician Relations (Personnel # 2), she agreed that the grievance process noted in the hospital's "Complaints" policy, and the regulatory requirements for a written response for Patient # 1 had not included: A. the steps taken to investigate the grievance, B. the name of the hospital contact person, C. the results of the grievance process, or D. the date of completion.