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Based on interview, record review and a review of the facility policy, it was determined the facility failed to have an effective system to ensure resolution of grievances and failed to provide patients with written notices which contained results of the grievance process for two (2) of ten (10) sampled patients (Patient #1 and #9). Interviews revealed Patient #1 reported billing concerns to the facility's Director of Digital Marketing on 11/12/14. The Marketing Director stated he forwarded Patient #1's complaint to the facility's risk manager; however, the facility did not have a system to ensure someone followed-up on grievances received on the marketing hotline. The facility failed to provide evidence that the grievance was investigated and that Patient #1 was notified of the resolution of the grievance. In addition, Patient #9's mother voiced a grievance on 11/3/14 that the "physician had a very bad attitude and did not take" the patients complaints seriously. However, a review of the grievance resolution letter returned to Patient #9 revealed, "Per hospital policy, the results of physician peer review may not be disclosed."

The findings include:

A review of the facility's policy titled Resolution of Patient Concerns and Grievances, not dated, revealed Patients or representative of the patient had the right to file a concern/grievance regarding any issue, including quality of care, discharge, billing, or administrative issues. Even though a review of the policy revealed that a complaint was considered resolved when the patient was satisfied with the actions taken on his/her behalf, the policy stated physician peer review proceedings were confidential, and those outcomes were not communicated to the complainants.

A review of the facility's grievance log on 12/08/14 provided no evidence Patient #1 had filed any complaints/grievances. The log further revealed the facility received a grievance related to Patient #9's care/treatment in the Emergency Room, which included reports that the "physician had a very bad attitude and did not take" the patient's complaints seriously.

An interview with Patient #1 on 12/08/14 at 9:00 AM revealed he/she had spoken with the Director of Digital Marketing on 11/12/14 related to "disappointment with the facility and their Physicians." Patient #1 stated the Director informed him/her that the complaint would be forwarded to a risk manager (RM #1). Patient #1 stated no representative had contacted him/her related to the complaint and "their lack of response is unacceptable."

An interview with the facility's Director of Digital Marketing on 12/08/14 at 3:55 PM confirmed he had discussed concerns voiced by Patient #1, with the patient on 11/12/14. The Director further stated that he sent RM #1 an e-mail on 11/12/14, related to the patient's complaints; however, he stated he did not follow up with the RM to ensure the patient's concerns were received and processed for resolution. The Director further stated he monitored the general inbox and received emails from patients. He stated he forwarded emails to the appropriate facility staff for resolution of complaints/grievances received, but did not have a system in place to follow-up to ensure patients' complaints/grievances were received by the appropriate staff for resolution.

An interview with RM #1 on 12/08/14 at 1:52 PM revealed she was not aware of the concerns voiced by Patient #1. The RM further stated "l looked through all my e-mails" and had not received any e-mails from the Director of Digital Marketing related to Patient #1's complaints. Continued interview with the RM confirmed Patient #9's mother filed a grievance on 11/03/14, which included concerns that "the physician had a very bad attitude" and had not taken the patient's complaints seriously. Further interview revealed she had issued a grievance resolution letter on 11/20/14, to Patient #9. The RM stated the letter provided the complainant with information that "the piece about your interaction with the physician has been sent to Medical Staff Quality Improvement Committee for review." The complainant was also informed that "Per hospital policy, the results of physician peer review may not be disclosed." The RM stated when complaints/grievances were received related to physician care and treatment, they were sent to Peer Review, and neither the RM, nor the complainants were notified of the findings related to concerns voiced about care and treatment provided by the facility's physicians.

An interview with the Director of Quality on 12/08/14 at 4:20 PM revealed she was not aware of any concerns voiced from Patient #1. Further interview revealed if complaints were sent via email, some type of follow up should have occurred to ensure the concern was received for processing and resolution. Continued interview revealed complaints/grievances received which involved physicians were referred to peer review for investigation. However, per facility policy, the complainant was never notified of actions taken related to concerns/grievances that involved facility physicians. The Director of Quality stated any actions taken related to a physician complaint was not disclosed.