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Based on interviews and record review, the facility did not follow their grievance process, in that, they did not meet their policy's specified time frames for this grievance, where: 1) "the grievance will be reviewed and an investigation initiated within seven days of receipt of grievance," and 2) "a written response of the hospital's decision will be sent as soon as possible (but no later than 30 days) ...if the investigation takes longer than 30 days to resolve, the patient (or complainant) will be kept informed either verbally or in writing, with an anticipated date of completion, for 1 of 1 patients (Patient # 1).

Findings included:

The complainant reported that he/she had initially voiced his/her grievance regarding Patient #1 at the neurosurgeon's (Personnel #12's) office, while being informed of the autopsy report, regarding the death of Patient # 1, four days after a scheduled surgery on 09/21/10. The complainant said he/she spoke to the Vice President (VP) of Risk Management (Personnel #2), who told him/her they would hold a Root Cause Analysis meeting, and about 2 weeks later, he/she received a call from the VP's office, advising him/her that this meeting was being scheduled to "find out what went wrong." The complainant said that when he/she asked when he/she would hear back with the results, he/she was told the week of December 6, 2010, but never heard from them again (by the time he/she submitted the complaint to the department on 01/10/11).

Policy & Procedure:

The facility's "Patient Grievance & Complaint Resolution Process" policy, last revised 06/09 which was in use at the time of this incident, noted the following under Procedure:
B. "Upon receipt of a patient grievance, the person receiving the information will document the grievance and forward it to the Director of Guest Services."
C. "The Director of Guest Services will work with the Department Director to coordinate a response to the person filing the grievance within 7 days, by letter or verbally with the following information:
? Acknowledgement of the receipt of the grievance.
? Grievance will be reviewed and an investigation initiated within seven days of receipt of grievance.
? A written response of the hospital's decision will be sent as soon as possible (but no later than 30 days) to the patient and will include name of contact person, steps taken to investigate, the results of the grievance process, and the date of completion. If the investigation takes longer than
30 days to resolve due to complexity, the patient will be kept informed either
verbally or in writing, with an anticipated date of completion.
E. "Quality of care issues...may be managed through the Medical Staff Peer Review
Committee, Nursing Peer Review Committee, and/or the Performance Improvement/Patient Safety Committee "
H. "Any grievance...that may require intense analysis for clinical quality of care
Issues...will be referred via the Director of Quality Services to the Event Analysis Team for review."
J. At the conclusion of the investigation, a written response will be provided to the
patient or his/her legal representative to include:
? The results of the grievance process.
? Steps included on behalf of the patient to investigate.
? Name of contact person.
? Date of completion.
K. All grievances/complaints are forwarded to Guest Services for tracking. In
addition, the appropriate Administrative officer will review all patient grievances
for appropriateness of response and ultimate resolution."

Interviews:

In an interview at 10:30 AM on 04/28/11 with the Vice President of Health Care Improvement/Risk Management (Personnel #2), she was asked if she had met with the complainant at neurosurgeon's office on 11/12/10, and she said "yes." She stated that the PA (Personnel #13) had called to tell her that the complainant was in their office and very upset over the autopsy report, and had asked if Personnel #13 could come and meet with him/her personally. Personnel #2 said that she had done this, and tried to defuse the situation. She verified that she had said they would do a Root Cause Analysis to look into the situation, and that her office had called the complainant later to let him/her know that this meeting was scheduled. She did not remember if the complainant had been told that he/she would hear results by the week of December 6, 2010, as alleged by the complainant.

In an interview at 3:55 PM on 04/26/11 with the Risk Analyst (Personnel # 4), she was asked if the hospital had documented a formal grievance had been received from the complainant, regarding the death of Patient #1, and she said "no." Personnel # 4 was asked when she first became aware of this grievance, and she said that it was through a telephone call she received from the VP of Risk Management (Personnel #2), on 11/12/10 regarding the complainant's concerns, which she had documented in her personal notes. When asked for documentation of her first interaction with the complainant, she provided a letter she had sent to him/her, dated 11/29/10 which said: " ...thank you for your patience as our team has conducted an analysis of the concerns related to [Patient #1's] recent hospitalization. Specifically, we have focused on the care, treatment and services provided to [Patient #1]. As part of our review, your grievance will be routed through the appropriate Medical Staff process...unfortunately, all proceedings are privileged and confidential, and therefore, I will not be able to disclose the outcome with you...," and gave the name and contact telephone number of the Risk Analyst. Personnel #4 verified this response letter was sent 17 days after the initial notification of this grievance on 11/12/10, and was not within the 7 day time frame required by their grievance policy.

When Personnel # 4 was asked for documentation of any further interactions with the complainant, she said she sent a second letter on March 11, 2011, when the hospital's investigation was completed, which read:

"...thank you for your patience as our team concluded the review process related to [Patient #1's] recent hospitalization. We recently received the results of the external Medical Peer Review. Although all proceedings are privileged and confidential, I can assure you a fair and unbiased review was conducted."

Personnel # 4 confirmed there was no documented interaction with the complainant between the dates of these 2 letters, dated 11/29/10 and 03/11/11. She also confirmed that the facility had no record of providing the complainant a response by December 6, 2010 specifically regarding the outcome of the Root Cause Analysis, allegedly promised to the complainant.

When asked why there was so much time between the 1st and 2nd letters to the complainant, the Risk Analyst said the facility had been waiting for the Medical Staff external Peer Review results. She verified the facility had not kept the complainant informed of the complex investigation process during this 3 and 1/2 month period, either verbally or in writing, with an anticipated date of completion, as required by their grievance policy.