HospitalInspections.org

Based on findings from document review and interview, in 1 of 6 (Patient #1) grievances reviewed, the facility did not ensure a timely resolution of the grievance. This lack of timely review hinders a resolution of the grievance.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Complaint and Grievance Management," dated 8/2016, it indicated a grievance requires formal written correspondence back to the patient/complainant. Efforts should be made toward resolution in real time when feasible. A letter will be sent to the complainant from the Performance Improvement (PI) office within 10 business days of receipt, acknowledging the issues, outlining the grievance investigation process and providing facility contact information. An investigation should be completed within 14 business days and forwarded to the PI office for documentation. Grievances should be concluded within 30 business days on average. Should a grievance take longer than 30 business days, contact with the complainant to update them is recommended.

-- Per review of the Complaint/Grievance File for Patient #1, a grievance was submitted on 4/3/17. However, as of 6/1/17, the file lacked documentation indicating an acknowledgement letter was sent to the complainant and any indication that an investigation and/or peer review had been completed.

-- Per interview of Staff A (Director of Quality Management) on 6/1/17 at 11:35 am, he/she acknowledged the above findings.