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Based on the review of medical records and interviews with hospital staff, it was determined that in one of one medical record with evidence of a patient fall, medical record # 1, the hospital failed to provide the patient or patient's representative with a written notice of the receipt of and investigation of a patient/family grievance according to time frames identified in hospital policy. Findings:

Medical record # 1 was reviewed and the Medical Surgical Unit Nurse Manager was interviewed at 1445 hours on 01/13/2010. Documentation in the medical record reflects that Patient # 1 sustained a fall on August 25, 2009 while hospitalized on the medical surgical unit. The unit manager reported and the review of medical record # 1 confirmed extensive hospital staff interaction with Patient # 1 and his/her family following the fall incident. Documentation in the medical record reflects that nursing staff implemented a number of interventions post fall that addressed Patient # 1's fall risk and the family's concerns. The unit manager reported that based on those actions, s/he believed that the patient's/family's concerns were addressed and resolved. As a result, the unit manager did not provide a written response to the patient's representatives. The unit manager reported that unit nursing staff convened a follow-up meeting in early September 2009 to review the fall incident. The unit manager invited Patient # 1's representatives to attend the meeting. The representatives declined. The unit manager reported that, again, s/he believed that the representatives' concerns about the incident were resolved.

The Risk Manager was interviewed at 1345 hours on 01/13/2010. The Risk Manager reported that the hospital received a written patient grievance in mid-November 2009. The written grievance identified circumstances related to Patient # 1's fall on August 25, 2009. The Risk Manager routed the written grievance to the medical surgical unit nurse manager and the VP of Patient Care Services.

The following policy was reviewed: Samaritan Health Services Manual of Administrative Policies, Complaint or Grievance, Patient/Family. The policy identified the hospital's process for responding to a patient/family complaint or grievance. The policy states that "Any staff member who becomes aware of a patient complaint or grievance should acknowledge receiving the complaint and make every effort to resolve the complaint at the time it is received." The policy also states that "If the staff member is unable to resolve the complaint, he/she will initiate a Patient/Family Concern Form." The Patient/Family Concern Forms are forwarded directly to the Department Manager for investigation and response/resolution.

The policy states the following at Policy # 5. "A patient or representative filing a grievance will be contacted within 3 business days to acknowledge receipt of the grievance. A written response will be provided within 7 business days after the investigation is complete that contains the steps taken on behalf of the patient to investigate the allegation, the results of the evaluation, the date of completion, and the name of the hospital contact for further information." The department manager receiving an unresolved complaint will attempt to contact the complainant within 3 business days to acknowledge receipt of the grievance and to elicit information, as needed, to further investigate and resolve the concern.

The unit manager and the VP of Patient Care Services were interviewed at 1445 hours on 01/13/2010. Both acknowledged receipt of the written grievance in mid-November and confirmed that as of 01/13/2010 no written response had been provided to the complainant in response to the receipt of the grievance. The VP of Patient Care Services confirmed that the hospital failed to respond to the written grievance within the time frames identified in hospital policy.


These findings also reflect non-compliance with the following Oregon Administrative Rule (OAR) for Hospitals:
OAR 333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).