HospitalInspections.org

Based on document review and staff interviews, it revealed the hospital failed to follow their own policy for keeping an accurate record of all grievances and complaints filed and the notification of the resolution to appropriate parties involved. This failure was identified in three (3) of five (5) grievances reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the policy titled "Handling of Patient Complaint/Grievance", effective date 01/11/2018 revealed in part: "Investigations will be resolved within 7 business days. Any delays in the investigation/resolution exceeding 7 business days from the date received by the Patient Advocates shall be reported to the administrative official(s), and patient, and will be completed within 30 business days. The patient advocate is responsible for keeping an accurate record of all grievances, of action taken, and their resolution. The Legal Aid Patient Advocate will notify the patient or patient's representative in writing using the Patient Grievance Form that the grievance has been resolved and what the resolution was within 7 business days of receiving complaint/grievance. If the grievance will not be resolved or completed within 7 business days, the Legal Aid Patient Advocate should inform the patient or patient's representative, the CEO or CEO designee in regards to when the investigation will be completed and that the hospital is still working to resolve the grievance and that the Legal Aid Patient Advocate will follow up with a written response when the investigation is complete with a targeted timeframe of 30 working days or less after the concern was received."

2. A review of the complaint log for June 2018 revealed no resolutions were documented for five grievances filed in June 2018. A review of the five (5) grievances filed revealed three (3) of five (5) grievances filed had no notification in writing to the patient or patient's representative of the resolution.

3. A grievance filed on 06/01/18 had no resolution documented on the complaint/grievance log for June 2018. There was no notification in writing to the patient or patient's representation in the grievance file. No signature of the patient advocate or date of contact was noted on the Patient Grievance Form.

4. A grievance filed 06/13/18 had no resolution documented on the complaint/grievance log for June 2018.

5. A grievance filed on 06/18/18 had no resolution documented on the complaint/grievance log for June 2018. There was no notifications in writing to the patient or patient's representative in the grievance file. No signature of the patient advocate was noted on the grievance form and no date of completion was noted on the Patient Grievance Form.

6. A grievance filed on 06/22/18 had no resolution documented on the complaint/grievance log for June 2018.

7. A grievance filed on 06/24/18 had no resolution documented on the complaint/grievance log for June 2018. Documentation on the patient grievance form by the patient advocate on 06/26/18 stated "Informed patient that this will be reported to the Nurse Manager. Patient transferred to Sharpe- July 5th- Case Closed." There was no notification in writing to the patient or patient's representative in the grievance file.

8. An interview was conducted with the Chief Executive Officer on 07/24/18 at 2:15 p.m. He concurred the patient advocate failed to follow the hospital policy for patient complaints and grievances.