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Based on interview and record review the hospital failed to follow facility policy and provide a written notice of grievance resolution for one patient (P10) of three patients reviewed for the hospital ' s grievance process.
The hospital' s failure to follow its grievance policy could affect the rights of all ten patients.
The findings were:
Review of the hospital' s Patient Grievance and Complaint policy last revised on September 2009 indicated the hospital' s governing body was responsible for the effective operation of the grievance process. The policy required the hospital to provide a written notice of its decision regarding a verbal or written complaint/grievance within seven days of the hospital' s receipt of the grievance with the name of the hospital contact person; steps taken on behalf of the patient to investigate the grievance; results of the grievance process; and date of completion.
Review of the hospital's Patient Rights policy undated required the facility to review every written or oral concern and to give a follow-up report to the person who filed the concern or grievance.
During an interview on 06/23/14 at approximately 1:30 p.m., P10' s family member (FM12) revealed she verbalized a complaint/grievance to Staff 9 and Emergency Department Physician (EDP10) on 01/21/14 at the facility regarding P10' s quality of care. FM12 said her complaint was not resolved during her meeting with Staff 9 and EDP10. FM12 indicated she did not receive any subsequent written resolution regarding her complaint.
An interview on 06/25/14 at approximately 12:15 p.m. with Staff 9 confirmed FM12 verbalized a complaint/grievance at the facility on 01/21/14 regarding P10' s care. Staff 9 indicated she reported the complaint to the hospital' s administration. Staff 9 indicated she had no knowledge of any written notice or resolution sent to FM12.
An interview on 06/25/14 at approximately 12:30 p.m. with EDP10 confirmed FM12 verbalized a complaint/grievance to him at the hospital on 01/21/14 regarding P10' s care. EDP10 indicated FM12' s grievance was not resolved at the meeting.
During an interview on 06/25/14 at approximately 12:45 p.m., Chief Nursing Officer (CNO) indicated she was responsible for ensuring the facility' s grievance process and policy was followed by all staff. The CNO said she had no knowledge of FM12' s verbal grievance on 01/21/14 and was not aware whether the facility provided any written notice of resolution as required by the facility' s Patient Grievance and Complaint policy. The CNO indicated she had no documentation of the grievance or subsequent written resolution to FM12.
During the Exit Conference on 06/25/14, the facility was provided an opportunity to give additional information. No additional information was given related to the patient's right to the grievance process.