HospitalInspections.org

Based on a review of 8 open and 3 closed records, it is determined that 1) hospital policy for responding to patient grievances erroneously allows for a written or a verbal response if done within 7 days, and 2) the hospital responded verbally to a grievance lodged by patient #1's significant other, which does not meet regulatory directives.

The hospital's policy for "Complaint and/or Grievance" defines a grievance as:

"3. Patient Grievance: Any written or verbal concern that is made to the hospital by a patient or patient ' s representative regarding services received that cannot be resolved promptly by staff present. Patient grievances include: ...

b. A formal or informal written or verbal concern regarding patient care, safety, abuse or neglect, or compliance with CMS Hospital Conditions of Participation."

This policy does not meet regulatory directives for responding to a grievance via a formal letter.

Further, an Administrator for the hospital states that they received a verbal grievance by patient #1's significant other on June 12th, which came directly to the Administrator of the Care Center regarding aspects of patient #1's care. An investigation followed resulting in a phone call to the grievant at the completion of the investigation, on June 16th. The phone call was the final response to the grievant, which does not meet regulatory directives for notice of the hospital decision to be by way of a formal letter.