HospitalInspections.org

Based on review of records, interviews with staff, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent. Nine of nine patient grievances filed had no evidence of investigation and written responses. One complaint to the Oklahoma State Department of Health (Department) was not listed in the grievance log and had not been identified as a grievance.

Findings:

1. The hospital's grievance policy, entitled Grievance and Complaint/Patient, Family with a review date of 01/12/2009, specified that grievances were considered any compliant, written or verbal, that could not be resolved at the time of the complaint by staff present. The policy stipulated the grievance would be completed as soon as possible with a written response to the complainant. The policy documented that if the grievance could not be completed within seven days, a written communication would be sent to the complainant stating the hospital was still investigating the grievance and final written correspondence would be sent within 30 days with the required information.

2. Review of nine grievances, taken from the grievance log for the time period of May and June 2010, did not show the grievances had been investigated and resolved with written responses provided to the complainants within the hospital's specified time period. Staff D stated on 09/01/2010 at 1500 that the grievances were awaiting action by other staff to let him know the results of the investigations.

3. Review of the hospital's incident reports for 2010 contained a grievance concerning the patient mentioned in the complaint to the Department. According to the information supplied by the hospital, the complaint was received at the hospital on 03/03/2010. The complaint documentation was not read/opened by supervisory/administrative staff until 07/27/2010. The hospital had not recognized the communication as a grievance and did not take the complaint through the grievance process.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to include, analyze and track grievances as part of the quality process to improve patient care and hospital services.

Findings:

1. Review of nine grievances, taken from the grievance log, did not show the grievances had been investigated and resolved with written response provided to the complainant within the hospital's specified time period. Staff D stated on 09/01/2010 at 1500 that the grievances were awaiting action by other staff to let him know the results of the investigations.

2. Review of the quality improvement meeting minutes for 2010 did not demonstrate grievances were part of the quality improvement program with analysis to improve hospital practices. Staff D stated that since he had been at the hospital grievances had not been reviewed.