HospitalInspections.org

Based on record review and interview the hospital's governing body failed to establish a process for prompt resolution of patient grievances resulting in increased risk of all patients having unresolved grievances. Findings include:

Policy Review:
Complaint Management and Resolution Process, #33.5.1, dated 1/2/13 was reviewed on 11/19/14 at 1030. The policy states: "The governing body of (hospital name) approves and is responsible for the effective operation of the Grievance process and delegates responsibility for review and resolution of grievances to the Patient Relations Department." The policy was not signed or approved by a member of the governing body and no documentation of a governing body statement approving this process could be found.

Interview:
On 11/19/14 at approximately 1200 staff A stated that a document by the governing body approving a grievance process could not be found.

Based on document review and interview, the facility failed to provide written notice of grievance review decisions to 3 of 3 patients who filed grievances (patients #3, #4 and #5), resulting in increased risk of lack of written response to all patient grievances. Findings include:

Policy Review:
Complaint Management and Resolution Process, #33.5.1, dated 1/2/13 was reviewed on 11/19/14 30. from 1030-1130. The policy states:
--"Patients and their families are informed of their right to voice complaints..."
--The policy defines a grievance as: "any formal or informal, verbal or written complaint (hereafter termed "complaint") that CANNOT be resolved at the time of the complaint by staff present" and as "any complaint related to abuse or neglect."
--The policy states: "A written response will be provided to the complainant within 7 days of receipt of the complaint."

Record Review:
1. On 11/19/14 from approximately 1000-1200 "Patient Relations Worksheet" notes by staff E were reviewed. A 9/3/14 note states: "She (patient #3's daughter) stated that her mother (patient #3) had been denied food, water and care while she has been here." A 9/4/14 note by staff E states: "(Staff G) spoke with (staff F), RN, and (staff H) Tech re: the night that the pt. (patient) thought staff was laughing at her and (staff F) reassured the patient that they were not talking about her at all."
2. On 11/19/14 from approximately 1000-1200 a 8/26/14 note by staff I was reviewed. The note states: "Called to pt's (patient #4's) room...Pt. has many complaints about stay, and thinks that we're keeping her here for something that's not that big of a deal...they didn't respond to my call light fast enough."
3. On 11/19/14 from approximately 1000-1200 a "Patient Relations Worksheet" by staff J, dated 9/22/14, was reviewed. The Worksheet states: "Pt (patient #5) wants to file a complaint for the way she was treated while here in ICU 9/1/14-9/3/14. Pt. (#5) states she was treated really bad." Patient #5 had moved from the ICU to the Psychiatric Unit when the grievance was filed.

Interview:
On 11/19/14 from approximately 1200-1230 staff A confirmed the record review findings (above) and verified that there was no documentation of any of the above grievances being resolved at the time they were filed. Staff A stated that there was no documentation of the facility sending written responses to follow-up on any of the grievances listed above. Staff A stated that the facility was not obligated to respond to grievances about care filed by family members unless the family member is the patient's legally appointed decision-maker.