HospitalInspections.org

Based on policy and procedure review, review of the Patient Complaint Grievance Log and interview, it was determined the Governing Body failed to be responsible for the effective operation of the grievance process in that the facility failed to establish a process for prompt resolution of patient grievances and adhere to their policy and procedure on providing patients an initial response in writing within 10 business days of the Patient Advocate receiving the grievance... The failure to provide Complainants with prompt resolution did not assure the patient and/or the patient's representative was informed of the resolution. The failed practice had the potential to affect all patients on census and all patients admitted to the facility. Findings follow:

A. Review of the policy and procedure "Compliant/Grievance" revealed:
"An initial response regarding a patient/family grievance will be provided in writing within 10 business days of the Patient Advocate receiving the grievance ...

B. Interview with the Patient Advocate on 07/06/12 at 1145, she stated there were no resolutions provided to the patient and/or family member.

Based on policy and procedure review, review of the Patient Complaint Grievance log and interview, it was determined the facility failed to provide the Complainant with written notice of the steps taken to investigate the complaint, the results of the investigation, the completion date of the investigation, and the name of a hospital contact person for 17 of 17 reported complaints. Without a written response, it could not be assured the patient and/or the patient's representatives were made aware of the steps taken on their behalf and the results of the grievance. The failed practice had the potential to affect all patients on census and all patients admitted to the facility. Findings follow:

A. Review of the policy and procedure "Compliant/Grievance" revealed "The written notice of the facility decision shall state:
The name of the contact person at the facility,
The steps taken on behalf of the patient to investigate the grievance,
The results of the grievance process, and
The date of completion."

B. Review of the Patient Complaint Grievance log revealed of the 23 complaints submitted 17 were not resolved immediately. There was no documented evidence 17 of 17 complainants were provided with written notice of the steps taken to investigate the complaint, the results of the investigation, the completion date of the investigation, and the name of a hospital contact person.

C. The Patient Advocate stated in an interview on 07/06/12 there was no response provided to the Complainants and/or family member.