HospitalInspections.org

Based on review of documents and staff interview it was determined the facility failed to ensure staff recognized a complaint and filed it according to hospital policy and procedure and failed to develope and send letters to the complainants in four (4) of five (5) complaints reviewed (#1,11,12,13). This can negatively impact patient care by leaving the patient without a resolution.

Findings include:

1. Hospital Policy titled Patient Complaints/Grievances, last revised 6/13, states in part: "UHC (University Health Care) will receive, investigate, and respond to any expressions of dissatisfaction, any complaints or grievances about patient care by patients, their families and or their visitors in a timely manner which will provide an opportunity for service recovery." B. Steps in Receiving and Investigating a Complaint or Grievance: "3. The individual who receives the complaint/grievance will enter it into the electronic incident reporting system with as much detail as possible." C. Response Process: "1. A follow-up response will be presented to the patient in a time frame appropriate to the complaint/grievance but not longer than 2 weeks (14 working days) after the receipt of the complaint/grievance. If a response in 14 days is not possible, the patient will be notified and a new response time will be negotiated."

2. Patient #1 was admitted to the hospital on 1/8/14 and discharged on 1/14/14. During a telephone call forty eight (48) to seventy two (72) hours post discharge from the Interim Director #2 of the fifth floor, the patient listed numerous complaints regarding her stay. These complaints were not documented in the electronic incident reporting system and the complainant did not receive a written response from the hospital.

3. During an interview on 3/25/14 at 0940 with the Interim Director #2 of the 5th floor, she revealed she calls all patient's forty-eight (48) - seventy-two (72) hours after discharge to ensure post hospital appointments have been schedule and medications are being taken properly. She also asks the patients about their stay and if they have any complaints. She stated when she called patient #1 she received numerous complaints. She did not enter these complaints into the electronic incident reporting system. She stated she talked to the nurses involved, but there is no documentation of discussions taking place. The patient never received a response from the facility acknowledging her complaint or the resolution of such complaint.

4. Patient #11 filed a complaint/grievance with the facility 2/11/14. This complaint/grievance was entered into the Electronic Incident Reporting System. The complaint was documented as resolved on 3/4/14 with no documentation indicating a letter had been sent to the complainant acknowledging receipt or resolution of the complaint.

5. Patient #12 filed a complaint/grievance with the facility on 12/3/13. This complaint/grievance was entered into the Electronic Incident Reporting System. The complaint was documented as resolved on 12/23/13 with no documentation indicating a letter had been sent to the complainant acknowledging receipt or resolution of the complaint.

6. Patient #13 filed a complaint/grievance with the facility on 9/6/13. This complaint/grievance was entered into the Electronic Incident Reporting System. The complaint was documented as resolved on 10/14/13 with no documentation indicating a letter had been sent to the complainant acknowledging receipt or resolution of the complaint.

7. Records 11, 12 and 13 were discussed with the Risk Manager on 3/26/14 at 1500 and she agreed with these findings.