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Based on review of documentation and interview it was determined that the hospital failed to ensure that it's own grievance policy was followed.

Findings were:
The hospital failed to ensure that it's own grievance policy was followed. The hospital received a grievance letter from a former inpatient who had received hemodialysis treatments in March, 2016. The letter (hospital staff provided copy to surveyor) was dated: July 01, 2016. This letter alleged serious quality of care issues related to the hospital inpatient hemodialysis unit. Review of the hospital response letter, dated July 28, 2016 revealed that it had been signed by an an individual whose signature block stated they were a "Senior Vice President." The letter stated: "I apologize for the delay in responding to your letter dated July 1, 2016. I have been absent from work but I can assure you that your letter has been taken seriously by me and the staff involved in your care. Let me first say that (name of Registered Nurse here) is not a UMC employee. He is employed by Fresenius, who provides our dialysis therapies. However, that does not mean that I am not concerned about the concerns that you have raised. In fact, just prior to my being gone, I met with a representative from Fresenius. You are correct in your statement that protecting patients should be UMC's number one priority and I can assure you that this situation will be investigated and the appropriate action taken."

The surveyor requested to see the formal hardcopy documentation regarding what the outcome of the above referenced investigation was. No documentation was provided.

Review of hospital policy: "Patient Grievances, SPP# PC-26.5" with an effective date of July 8, 2014 stated: " University Medical Center (UMC) will address patient complaints and grievances in a timely, reasonable, and consistent manner. " " B. Grievance 2. A written complaint is always considered a grievance. 3. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for late resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. " " 4. Verbal or written complaints about abuse, neglect, patient harm, or hospital compliance with CMS requirements are grievances. " Page 3 of the policy stated: " D. As promptly as possible, but usually within seven business days of receiving the grievance, the Grievance Committee shall complete the investigation and a designated committee member shall provide a written response to the patient or patient's representative. 1. If the grievance is not resolved within seven business days, members of the Grievance Committee; who appropriate for the resolution, will notify the patient in writing that the review is still in process. 2. The written response will address the substance of each grievance and will include: a. the name of the contact person at UMC, b. the steps taken to investigate the grievance, c. the results, and d. the date of completion. " "V. Recordkeeping The Service Development Office will keep a record of each grievance, the investigation, and the written response for a period of ten years after the grievance."

In an interview with the Hospital's Vice President of Quality on the afternoon of 1/30/2017 it was confirmed that the the hospital had not followed it's own policy as an investigation had not been completed within seven business days of receiving the grievance from patient #1.

In an interview with the Accreditation Manager on 1/31/2017 the surveyor was informed that the 01 July, 2016 grievance letter from patient #1 had not been received by the Service Development Department.