HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to follow the hospital policy time frames for the provision of a response for patient grievances for three discharged patients (#43, #45, and #46) of four discharged patient grievances reviewed. This practice had the potential to affect all patients that filed a grievance causing the complainant to be unaware of the status, or resolution of their grievance. The hospital census was 187.

Findings included:

Review of the hospital's policy titled, "Complaints and Grievances/Opportunity for Improvement (OFI)," revised 05/11/22, showed that:
- A grievance was defined as a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the OFI is not resolved at the time it is received by staff present), abuse or neglect, of issues related to the hospital's compliance with the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation (CoPs).
- Grievances should be resolved, on average, within seven business days or less.
- If the resolution of the grievance is completed within seven business days, a letter with the findings of the investigation shall be sent within seven business days of receipt.
- If the grievance is of a complex nature and the resolution of the grievance is determined to take longer than seven business days, a letter will be sent to the patient or patient's representative within seven business days of receipt to acknowledge the receipt of the grievance and inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within 30 business days.
- A grievance would be considered resolved and closed when the customer/patient has expressed satisfaction with the actions taken by the hospital.
- If the resolution of a grievance will take longer than 30 business days, a written update must be sent to the patient or patient's representative indicating the hospital is still working to resolve the grievance, with an expected timeframe for resolution.
- Documentation in the OFI report system must describe the rational for a grievance taking longer than thirty business days to resolve.

Review of Patient #43's grievance form titled, "SSM Opportunity for Improvement," showed that the grievance was received by the hospital and dated 03/08/22. A letter dated 03/17/22, stated that a written response would follow within 30 days after speaking with staff and a review of the medical record. A letter dated 09/07/22 was sent with the results of the investigation. This was 126 business days after the initial complaint was received. No letter was found addressed to the patient stating that more time was need to investigate, nor documentation in the report system describing the rational for the grievance taking longer than 30 days.

Review of Patient #45's grievance form titled, "SSM Opportunity for Improvement," showed that the grievance was received by the hospital and dated 03/19/22. A letter dated 03/22/22, stated that a written response would follow within 30 days after speaking with staff and a review of the medical record. A letter dated 09/07/22 was sent with the results of the investigation. This was 117 business days after the initial complaint was received. No letter was found addressed to the patient stating that more time was need to investigate, nor documentation in the report system describing the rational for the grievance taking longer than 30 days.

Review of Patient #46's grievance form titled, "SSM Opportunity for Improvement," showed that the grievance was received by the hospital and dated 07/06/22. A letter dated 07/12/22, stated that the hospital was still working to resolve her concerns and a written response would follow within 30 days A letter dated 08/23/22 was sent with the results of the investigation. This was 35 business days after the complaint was received. No letter was found addressed to the patient stating that more time was need to investigate, nor documentation in the report system describing the rational for the grievance taking longer than 30 days.

During an interview on 09/07/22 at 3:36 PM, Staff NN, Systems Manager, stated that a first response to a grievance should be within seven business and if the grievance was not resolved within that time, a final response should be received by the complainant within 30 business days.

During a concurrent interview on 09/07/21 at 3:36 PM, Staff OO, Regulatory Specialist, stated that a hospital audit during the week of 09/05/22, showed grievances which originated in March did not receive a final response, and that approximately ten letters that were sent to complainants were not within the time frame prescribed.