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Based on policy review grievance file review and staff interview the staff failed to provide written notice of resolution of a grievance containing the results of the grievance process, and the date of completion.
in 2 or 2 grievance files reviewed (#9 and #10).

The findings include:

Review of hospital policy "Grievance and Resolution Procedure: Patient and Family" revised 9/11 revealed "6. Once the investigation is completed, the patient or family member will receive a response in writing within seven (7) days of the grievance filed date or be advised as to the reason for the delay and when an answer may be expected. The answer will include actions taken and decisions as determined."

1. Grievance file review of Patient #9 revealed the patient filed a grievance on 12/30/2011 regarding her care while hospitalized after admission on 12/26/2011. File review revealed a letter dated 1/9/2012 to the patient informing the patient an investigation had been completed. Review of the letter did not reveal any documentation of resolution or the results of the grievance process. Review of the letter revealed documentation of actions that were planned to be taken for the investigation.

Interview with administrative quality staff and patient advocate staff on 1/27/2012 at 1130 the letter was considered as the resolution letter to the complainant. The interview confirmed the letter did not contain the results of the investigation of the patient's grievance.

2. Grievance file review of Patient #10 revealed the patient filed a grievance on 12/4/2011 regarding her care while hospitalized after admission on 12/5/2011. File review revealed a letter dated 12/21/2011 to the patient informing the patient an investigation had been completed. Review of the letter did not reveal any documentation of resolution or the results of the grievance process. Review of the letter revealed documentation of actions that were planned to be taken and sources of referrals to complete the investigation.

Interview with administrative quality staff and patient advocate staff on 1/27/2012 at 1130 the letter was considered as the resolution letter to the complainant. The interview confirmed the letter did not contain the results of the investigation of the patient's grievance.

NC00077271
NC00077422
NC00078046