HospitalInspections.org

Based on review of documents and interview with staff, the facility failed to ensure that the time-frame for response to a patient grievance was in accordance with facility policy for 1 of 1 patient whose record was reviewed.

Findings were:

Facility policy 900-RI-165, entitled Patient Grievance and Complaint Resolution Process, last reviewed in January 2011, states that a grievance is defined as a written complaint letter from patients or their representative. The Patient Grievance Committee is responsible for review and resolution of the grievance. Upon receipt of the grievance, hospital Health Care Improvement (HCI) staff will investigate and communicate with complainants who file cases involving risk and/or quality of care issues. A written response is to be sent to the complainant no later than 30 days after the complaint is filed; if the investigation takes longer than 30 days, the complainant will be notified of the anticipated date of completion.

A review of a facility Guest Relations report revealed that a complainant, the spouse of Patient #1, submitted a written grievance on 1/14/2012. An in-person interview with the Vice President of Health Care Improvement was conducted the afternoon of 3/6/12 in a facility conference room. According to the Vice President, the response letter did not go out to the complainant until 3/6/2012, which was 51 days after receipt of the letter of complaint. The complainant was not informed by the 30th day that the investigation response would take longer than 30 days.