HospitalInspections.org

Based on record review and interview the facility failed to follow its Complaint/Grievance Policy as identified in 8 of 21 (#1,#2, #3, #4, #5, #6, #7, #8, #9, #10 #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) patient grievances identified.

On 3/25/2013 at 1:00 PM in the conference room the facility policy identified as "Patient Complaint/Grievance" with review date of 10/11 revealed the following under Procedures:
"6.0 The Patient Relations Coordinator will ensure that a written response is sent to the appropriate party regarding the grievance. If a resolution cannot be obtained within 7 days of the receipt of the grievance, an acknowledgment letter will be sent to the complainant notifying them of this and provide a reasonable time frame for notification of the final resolution. Final notification will take no longer than 30 days, a letter will be sent to complainant as to when to expect the resolution. The written response will include the steps taken to investigate the grievance, the resolution of the grievance process and the date of completion along with the name and phone number of the Patient Relations Coordinator".


On 3/25/2013 at 2:00 PM in the conference room the facilities grievance investigations for 3 months were reviewed and revealed 8 patients whose complaint took greater than 7 days to investigate and resolve. They are as follows:
Pt #1 submitted a written complaint on 2/5/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent to the complainant on 2/26/2013. Resolution was in 22 days.

Pt #2 submitted a written complaint on 1/2/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 1/18/13. Resolution was in 21 days.

Pt #8 submitted a written grievance on 1/23/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 2/5/13. Resolution was in 13 days.

Pt #14 submitted a written grievance on 2/18/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/20/13. Resolution was in 33 days.

Pt #15 submitted a written grievance on 2/19/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/6/13. Resolution was in 16 days.

Pt #16 submitted a written grievance on 2/26/13. There was no documentation of resolution..

Pt #17 submitted a written grievance on 3/1/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 3/18/13. Resolution was in 17 days.

Pt #19 submitted a written grievance on 3/6/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/18/13. Resolution occurred at 13 days.

On 3/25/2013 at 1:30 in the conference room and interview with the Patients Resolutions Coordinator confirmed only one letter was sent. The Coordinator also confirmed at times a phone call was placed to notify the patient of resolution or to actually resolve the complaint. In case such as that no letter was sent.

The facility failed to follow it's policy regarding notifying a patient with a written letter if the complaint could not be resolved in 7 days.

Based on record review and interview the facility failed to follow its Complaint/Grievance Policy as identified in 8 of 21 (#1,#2, #3, #4, #5, #6, #7, #8, #9, #10 #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) patient grievances identified.

On 3/25/2013 at 1:00 PM in the conference room the facility policy identified as "Patient Complaint/Grievance" with review date of 10/11 revealed the following under Procedures:
"6.0 The Patient Relations Coordinator will ensure that a written response is sent to the appropriate party regarding the grievance. If a resolution cannot be obtained within 7 days of the receipt of the grievance, an acknowledgment letter will be sent to the complainant notifying them of this and provide a reasonable time frame for notification of the final resolution. Final notification will take no longer than 30 days, a letter will be sent to complainant as to when to expect the resolution. The written response will include the steps taken to investigate the grievance, the resolution of the grievance process and the date of completion along with the name and phone number of the Patient Relations Coordinator".


On 3/25/2013 at 2:00 PM in the conference room the facilities grievance investigations for 3 months were reviewed and revealed 8 patients whose complaint took greater than 7 days to investigate and resolve. They are as follows:
Pt #1 submitted a written complaint on 2/5/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent to the complainant on 2/26/2013. Resolution was in 22 days.

Pt #2 submitted a written complaint on 1/2/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 1/18/13. Resolution was in 21 days.

Pt #8 submitted a written grievance on 1/23/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 2/5/13. Resolution was in 13 days.

Pt #14 submitted a written grievance on 2/18/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/20/13. Resolution was in 33 days.

Pt #15 submitted a written grievance on 2/19/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/6/13. Resolution was in 16 days.

Pt #16 submitted a written grievance on 2/26/13. There was no documentation of resolution..

Pt #17 submitted a written grievance on 3/1/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent on 3/18/13. Resolution was in 17 days.

Pt #19 submitted a written grievance on 3/6/13. The investigation could not be completed within 7 days. There was no documentation a letter was sent to the complainant explaining this or giving the complainant a reasonable expectation of when the grievance might be resolved. A resolution letter was sent 3/18/13. Resolution occurred at 13 days.

On 3/25/2013 at 1:30 in the conference room and interview with the Patients Resolutions Coordinator confirmed only one letter was sent. The Coordinator also confirmed at times a phone call was placed to notify the patient of resolution or to actually resolve the complaint. In case such as that no letter was sent.

The facility failed to follow it's policy regarding notifying a patient with a written letter if the complaint could not be resolved in 7 days.