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Based on policy review and staff interview it was determined the Corporate Compliance Officer (CCO) failed to follow the hospitals process for filing a patient's grievance with documentation and follow-up for one (1) of one (1) charts reviewed. This failure has the potential to adversely impact all patients that wish to file a complaint or grievance in this facility.

Findings include:

1. The policy "Patient Grievances (Patient Complaints)", last reviewed 06/13/13, was provided for review. The policy states: "All complaints shall be documented utilizing the electronic Complaint Reporting System". It further states: "Any correspondence exchanged regarding the situations shall be placed in the electronic Complaint Reporting System". "Every effort should be made to resolve major complaints within seven (7) days."

2. An interview was conducted with the CCO on 08/12/13 at 1025. He stated that he did know who patient #1 on the identifier list was and that he did speak to her a few times when she came unannounced to the hospital to speak with him. When asked if he documented any of his conversations with patient #1 he stated : "I don't think so, I can check". When asked if he filled out an incident report, he stated no. He does remember receiving a certified letter from patient #1 but does not remember if he kept the letter. Upon asking numerous times if any documentation had been found the only documentation found was the certified letter from the patient. The hospital did not provide any evidence of a written response to the complainant.

3. The Director of Quality Management concurred with the above findings on 08/14/13 at 1130.

Based on policy review and staff interview, it was determined the hospital failed to follow their own policy to provide the complainant with a written response regarding the resolution of the complaint for one (1) of one (1) charts reviewed (patient#1). This has the potential to negatively affect all patients from having the right to receive a written response as to the outcome of the hospital investigation.

Findings include:

1. The policy, "Patient Grievances (Patient Complaints)", last reviewed 06/13/13, was provided for review. The policy states: "The exact time required to respond to a major complaint will depend upon the nature and complexity of the complaint. However, the patient should be notified if the investigation is going to be longer than seven days. This notification is documented and includes the expected date of the resolution. A formal letter is sent to the patient."

"In resolution of the complaint the facility is required to send a final written response to the complainant which addresses the following items: name of the hospital contact person, steps taken on behalf of the patient to investigate the complaint/issue, results of the investigation, and the date of completion".

2. An interview was conducted with the CCO on 08/12/13 at 1025. He stated, he received a phone call from the patient on 04/04/13 and discussed the concerns with her medical record over the phone. He did call the patient several times and would speak with her when she came to the hospital without an appointment to meet with him. He did vaguely remember receiving a certified letter from the patient on 05/17/13 but has had no contact with the patient since May. When asked about any documentation regarding this complaint he stated, "I never kept any record of our meetings or phone calls". He stated, "I just assumed after our last meeting the issue was resolved".

3. Upon numerous requests for documentation of the investigation, the facility could only provide the certified letter received from the patient. No other documentation was found. The hospital did not provide the patient with a written response per hospital policy.

4. An interview was conducted with the Director of Quality Management on 08/14/13 at 1130. She concurred with the above findings.