HospitalInspections.org

Based on document reviews and staff interviews it was determined the hospital failed to follow their own policy for patient grievances. This deficient practice was identified in four (4) of four (4) records reviewed (patient #1, patient#2, patient #3, and patient #4). This failure has the potential to adversely affect the rights of all patients.

Findings include:

1. Review of the hospital policy titled "Patient Grievance Procedure, revised 9/13/13, revealed in part: Grievances will be investigated and responded to within 20 calendar days, excluding holidays.

2. A review of the complaint/grievance log for October 2017 to December 2017 was conducted on 12/12/17. A grievance was filed for patient #1 on 10/31/17 and 10/23//17, for patient #2 on 10/4/17 and 11/9/17, for patient #3 on 10/30/17 and for patient #4 on 11/13/17.

3. A review of the hospital's Patient Grievance form revealed a grievance for patient #1 was filed on 10/31/17. An investigation was completed by the Legal Aid Advocate and the hospital investigator, and a letter of conclusion was sent to the hospital on 11/20/17. A letter of response was mailed to the patient advocate on 11/29/17. Further review revealed a second Patient Grievance form for patient #1 was filed on 10/23/17. An investigation was completed by the Legal Aid Advocate and the hospital investigator, and a letter of conclusion was sent to the hospital on 11/5/17. A letter of response was mailed to the patient advocate on 11/17/17.

4. A review of the hospital's Patient Grievance form revealed a grievance for patient #2 was filed on 10/4/17. An investigation was completed by the Legal Aid Advocate and the hospital investigator, and a letter of conclusion was sent to the hospital on 10/24/17. A letter of response was mailed to the patient advocate on 10/27/17. Further review revealed a second Patient Grievance form for patient #2 was filed on 11/9/17. An investigation was completed by the Legal Aid Advocate and the hospital investigator, and a letter of conclusion was sent to the hospital on 11/29/17. No letter of response had been sent to the patient advocate by the hospital.

5. A review of the hospital's Patient Grievance form revealed a grievance for patient #3 was filed on 10/30/17. An investigation was completed by the Legal Aid Advocate and the hospital investigator, and a letter of conclusion was sent to the hospital on 11/20/17. A letter was mailed to the patient advocate on 11/29/17.

6. A review of the hospital's Patient Grievance form revealed a grievance for patient #4 was filed on 11/13/17. No letter of investigation/conclusion was noted. No letter of response has been sent to the patient advocate by the hospital.

7. A review was conducted by the Administrative Secretary on 12/13/17 at 11:45 a.m. of the grievance filed for patient #4, she stated they were waiting on the investigation report from the Legal Aid Advocate and hospital investigator.

8. A review was conducted by the Chief Executive Officer on 12/12/17 at 1:00 p.m. of the grievances filed for patient#1, patient #2, patient #3, and patient #4, he concurred the policy has not been followed.