HospitalInspections.org

Based on document review and staff interviews it was revealed the facility failed to follow their own policy for keeping an accurate record of notification of the resolution to appropriate parties involved after a complaint/grievance was filed. This failure was identified in one (1) of two (2) grievances reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the policy titled "Patient Grievance Policy" revised 5/12 stated in part: "A timeframe of seven days to issue a response to the patient is appropriate for grievances that require investigation. In the event that the investigation and resolution process should require additional time due to extenuating circumstances, the explanation of the delay should be communicated to the patient, or his/her legal representative and the facility should follow-up in writing within a stated number of days."

2. A review of the complaint log for July 2021 revealed no notification of the resolution was documented for one (1) of two (2) complaints/grievances reviewed. Status was marked as in process.

3. An interview was conducted with the Chief Nursing Officer in the administrative conference room on 8/25/21 at 1:00 p.m. She stated she was unable to locate the notification of the resolution to appropriate parties involved for one (1) of two (2) complaint/grievances reviewed. She concurred there is no proof the facility policy was followed.