HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to provide written response to patient grievances within seven (7) days of referral to the grievances committee as required by hospital policy. This deficient practice was identified in one (1) of (1) grievances that was reviewed that did not have a written response from January 1, 2011 to August 2011 (Patient #10). Failure to promptly respond to a patient's grievances can result in a patient's issue not being addressed with a failure to correct any areas of deficient practice and a violation of the patient's rights.

Findings include:

1. The hospital complaint and grievances management and patient satisfaction policy (reviewed 1/10) revealed in part the following: "Within seven (7) days of referral to the Grievance Committee the Risk Manager or another member of the committee shall upon the conclusion of the Committee investigation, prepare and send to the party asserting the Grievances a written response of the findings and conclusions of the committee and any actions that have been or will be taken."

2. The hospital complaint file for patient #10 was reviewed on 8/29/11. The file lacked documentation of an investigation with conclusions relative to patient's #10 complaint that had been filed with the hospital on 1/25/11. There was a letter dated 8/8/11 that was sent to the patient concerning her Emergency Department visit in January 2011. There was no documentation as to the reasons for the six (6) month delay in providing the patient a written response to her complaint.

3. The Risk Manager was interviewed on 8/31/11 at 1540 hrs. He stated this complaint had been brought before the Grievances Committee in the February Meeting but there must have been a question and the complaint was pulled while awaiting additional information. He stated he realized in March the complaint had not been resolved and started asking for the final report which could not be located. He asserted he has had numerous phone conversations with the patient about her January ED visit and a letter had not been sent until this August.