HospitalInspections.org

Based on interviews and record review, in it's resolution of the submitted grievance,the hospital did not meet federal regulatory requirements, nor appropriately follow their hospital policy, in that, A) they did not produce evidence that they had performed a complete investigation, and B) they had not provided the patient's (Patient # 1) family member a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient's family to investigate the grievance, the results of the grievance process, or the date of completion.

Findings included:

In an interview at 11:30 AM on 11/30/10 with the Director of Health Care Improvement (Personnel #2), when asked if Patient # 1's family had filed a complaint or grievance with the hospital, either during her hospitalizations or soon after her death, she said "no." She stated that the initial grievance was not received until 09/28/09, by letter, almost 2 years after Patient # 1's death on 10/23/07. Personnel # 2 said that the grievance letter was received by their Guest Services, who notified the Risk Manager, and then forwarded the letter to their corporate lawyers for investigation and follow-up, as this looked like it may be a litigation case. When asked for the hospital's Grievance Log, she referred the surveyor to the Risk Manager.

In an interview at 1:30 PM on 11/30/10 with the Risk Manager (Personnel # 3), when asked to explain the hospital's grievance process, she produced their "Patient Grievance & Complaint Resolution Process" policy, last revised 06/09.

Review of the hospital's "Patient Grievance & Complaint Resolution Process" policy, last revised 06/09, noted the following:
- The purpose is "to establish a method for receiving, reviewing and responding to grievances and complaints to ensure that concerns relating to quality of care...are addressed in a timely manner."
- A patient grievance is defined as "all written complaint letters...from patients or their representative."
- "The Patient Grievance Committee is responsible for review and resolution of patient grievances..."
- "In the resolution of patient grievances, other departments/committees including but not limited to Risk Management...Ethics and Compliance Committee, Performance Improvement/Patient Safety Committee and Medical Staff Peer Review Committee may be involved as needed."
- "Upon receipt of a patient grievance, the person receiving the information will document the grievance and forward it to the Director of Guest Services."
- "The Director of Guest Services will work with the Department Director to coordinate a response to the person filing the grievance within 7 days, by letter or verbally with the following information:
1) Acknowledgement of the receipt of the grievance.
2) Grievance will be reviewed and an investigation initiated within 7 days of receipt of the grievance.
3) A written response of the hospital's decision will be sent as soon as possible (but no later than 30 days) to the patient and will include name of contact person, steps taken to investigate, the results of the grievance process, and the date of completion. If the investigation takes longer than 30 days to resolve due to complexity, the patient will be kept informed either verbally or in writing, with an anticipated date of completion."
-"Quality of care issues...may be managed through the Medical Staff Peer Review Committee, Nursing Peer Review Committee, and/or the Performance Improvement/Patient Safety Committee."
- "Risk Management will be informed of any grievance...in which litigation is anticipated."
-"Any grievance...that may require intense analysis for clinical quality of care issues...will be referred via the Director of Quality Services to the Event Analysis Team for review."
- "At the conclusion of the investigation, a written response will be provided to the patient or his/her legal representative to include: the result of the grievance process, steps included on behalf of the patient to investigate, name of contact person, date of completion."
- "All grievances...are forwarded to Guest Services for tracking. In addition, the appropriate Administrative officer will review all patient grievances for appropriateness of response and ultimate resolution."
- "Grievances...are reviewed for trends, with data submitted to the Performance Improvement/Patient Safety Committee on a quarterly basis."
- "Exclusions: Active professional or general liability claims , cases in litigation or under investigation by healthcare regulatory agencies."

In a continuing interview at 1:30 PM on 11/30/10 with the Risk Manager (Personnel # 3), when asked to describe the hospital's grievance process used in this case, she stated the following sequence of events:
-On 09/21/09 Guest Services had received the grievance letter from Patient #1's daughter (complainant), and forwarded this letter to her and to the hospital's corporate lawyers.
She stated that she had called to talk with the complainant that day, informing her that she would be her contact person, and that the hospital would investigate her grievance. She confirmed that she had not told the complainant the steps included on behalf of the patient to investigate, or a possible completion date for the investigation.

The Risk Manager produced her computer record (Grievance Log), that was a summary of the allegations, a brief interview with the named nurse in the allegation (Personnel # 6), and a call to the Nurse Manager (Personnel # 5) to ask if she knew about this case. The Risk Manager said that she had then referred this case to the Physician Peer Review Committee, and produced documents that verified this had been completed by that committee on 03/10/10, with the case rated at a level 0, indicating that "all care was deemed appropriate."

The Risk Manager verified that the hospital had not performed a Root Cause Analysis on this case, and that it had not been referred to the Nursing Peer Review Committee. She also confirmed that no further steps had been taken within the hospital regarding any further investigation, as the hospital's corporate lawyers would perform their own investigation, including staff interviews. She verified that this was the hospital's policy, as noted above in the "Exclusions" when a case may go to litigation.

She also confirmed that she had not sent a written response to the complainant within 30 days, that would have included the name of the contact person, steps taken to investigate, the results of the grievance process, and the date of completion. She said that this would have been their process for any grievance that was not considered a possible litigation case. When shown the federal regulations that required this process, she agreed that it did not allow another process for litigation cases.

In an interview at 11:30 AM on 12/02/10 with the Director of Health Care Improvement (Personnel #2), when asked to see the investigation documentation that had been done by the hospital corporate lawyers, she stated that she could not show me those documents, as the corporate lawyers would not release them for the federal/state surveyor's review, based on confidentiality. She confirmed that she understood that A) the hospital would be cited as not having performed an investigation into this grievance (no documentation produced to verify), and B) for not following the hospital's Grievance policy, whereas the "Exclusion" portion of that policy does not meet federal requirements.