HospitalInspections.org

Based on record review and interview, the hospital failed to establish and implement a policy requiring notification to patients when grievance investigations have not been or will not be completed within the hospital's specified time frame. The hospital further failed to establish and implement a policy requiring that patients whose grievances are not resolved within this time frame be notified of a date by which they will receive a follow-up written response. The findings are:
A. Review of the Miners' Colfax Medical Center policy entitled, "Patient Grievance Policy," updated 02/09/10, revealed, in paragraph 6.2.5, the statement, "The investigation will be complete in 7 days from receipt of complaint." The policy contained no discussion of procedures to be followed in the event that a grievance investigation had not been completed within that period.
B. Review of the documentation associated with a patient grievance that was received on 05/04/10 revealed a final response from the facility dated 05/25/10. There was no evidence that a follow-up response had been sent to the patient by the facility at the expiration of the seven-day investigation period established in the facility's policy.
1. On 08/26/10 at 2:30 pm, during interview, the Care Managenment, Quality/Risk Management Nurse stated that she spoke to the patient concerning the patient's grievances on the day after the grievance was received. The Care Management, Quality/Risk Management Nurse further stated that she told the patient that she would look into the matter. She verified that no written interim follow-up response was sent to the patient prior to the facility sending the final response.
C. Review of the documentation associated with two grievances from a single patient that were dated 04/21/10 and 04/22/10 revealed a final response from the facility dated 05/25/10. There was no evidence that a follow-up response had been sent to the patient by the facility at the expiration of the seven-day investigation period established in the facility's policy.
1. On 08/26/10 at 2:30 pm, during interview, the Care Managenment, Quality/Risk Management Nurse stated that she and the facility Billing Manager met with the patient on 04/22/10, the date of the patient's discharge, concerning the patient's grievances. She stated that she considered this meeting to have constituted an interim response to the patient. She verified that no written interim follow-up response was sent to the patient prior to the facility sending the final response.