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Based on review of hospital policy, grievance file reviews, and staff interviews, the hospital staff failed to acknowledge receipt and resolution of a grievance to a patient or patient's representative per hospital policy for 1 of 2 grievance files reviewed (#1).

The findings include:

Review of the hospital's policy, "Patient Complaints/Grievances", revised 11/2009, revealed, "Definitions: ...Grievance - A patient issue that staff has not been able to resolve promptly is a grievance. ...Upon receipt of a grievance, personnel responsible for follow-up: ...2. Acknowledges receipt of a grievance, in writing, to patient/patient representative within 7 days....8. Provides written response regarding resolution of grievance to the patient/patient representative: ...b. If not resolved within the 7 days, a follow-up letter that substantively addresses the grievance and resolution will be sent within 30 days. ...".

Review of Grievance File #1 on 12/04/2013 revealed a patient filed a complaint with the hospital's grievance coordinator on 09/25/2013 regarding care received in the hospital's emergency department. Review of the file revealed no documentation of a letter acknowledging receipt of the grievance. File review revealed a letter to the complainant dated 10/17/2013 by the corporate risk manager (22 days after grievance filed). File review on 12/04/2013 revealed no documentation of a follow-up letter to address the
grievance and resolution (48 days after grievance filed).

Interview on 12/04/2013 at 1300 with administrative staff confirmed a grievance was received on 09/25/2013 and an acknowledgement letter was not sent within 7 days and a follow-up letter was not sent within 30 days. Interview confirmed the hospital's grievance policy was not followed.

NC00093494