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Tag No.: A0122
Based on document review and interview, it was determined for 1 (Pt #1) of 2 grievances reviewed, the hospital failed to ensure the grievance was investigated within the 5 day timeframe per policy.
Findings include:
1. The hospital 's policy entitled "Complaints/Complements-PRIDE Program" (revised 01/2015) was reviewed on 8/4/15 at approximately 1:00 PM and required, "Definitions: ...A grievance constitutes a more significant and complex issue that requires investigation...Patient complaints that are considered grievances also include situations ...with a complaint regarding the patient ' s care or with an allegation of abuse."
2. The complaint from Pt. #1 was reviewed on 8/4/15 at approximately 10:00 AM. The hospital's Clinical Resource Nurse (E #3) received a complaint from Pt #1 on 6/7/15 that included, " ...had some complaints about her stay in PCU ... she felt very "disrespected". The hospital's response and follow up to this complaint was initiated on 6/22/15 (15 days after receipt of complaint).
3. On 8/4/15 at approximately 1:15 PM, an interview was conducted with E #3. E #3 stated she had received an email from E #4 on Monday, 6/8/15 regarding the complaint from Pt #1. E #3 stated that she spoke with E #1 and E #2 about the complaint. E #3 stated Pt #1 had been discharged before E #3 had a chance to talk with her about the complaint. When asked for documentation of any investigation or dates of E #3's communication with E #1 and E #2 prior to 6/22/15, E #3 could not provide dates or produce this documentation.
4. On 8/5/15 at approximately 1:40 PM, an interview was conducted with the Director of Surgical Services (E #7). E #7 stated that this complaint was considered a grievance by the hospital per policy. E #7 stated that E #4 began the investigation when she spoke with E #1 on 6/7/15, but E #3 should have documented her investigation within 5 days of receipt of the complaint.
Tag No.: A0123
Based on document review and staff interview, for 1 (Pt #1) of 2 grievances reviewed, the hospital failed to send a response to the grievance which communicated the investigation and the outcome of the grievance.
Findings include:
1. The hospital ' s policy entitled " Complaints/Complements-PRIDE Program " (revised 01/2015) was reviewed on 8/4/15 at approximately 1:00 pm and required, " ...A letter detailing the steps taken to investigate the grievance, the results of the grievance process, and the date of completion will be sent within 60 days of receipt of the complaint/grievance ... "
2. The grievance regarding Pt #1 was reviewed on 8/4/15 at approximately 10:30 am and included the grievance was received by the hospital on 6/7/15.
3. The hospital's response and follow up to the grievance was reviewed on 8/4/15 at approximately 10:30 am. A response letter dated 7/10/15 was sent to Pt #1 from the hospital in regards to her grievance. The letter did not include the outcome or that the complaint was still under investigation. The letter also lacked communication of the steps taken to investigate the complaint.
4. On 8/5/15 at approximately 1:40 pm, an interview was conducted with the Director of Surgical Services (E #7). E #7 stated that this grievance was still under investigation, and Pt #1 should have been informed that the hospital was investigating this grievance.