HospitalInspections.org

Based on record review and interview, facility failed to ensure an effective process for resolving grievances. The facility failed to follow its established grievance process in identifying and resolution of patient's grievance in 1 of 3 patients (ID#1).

Findings include:

Record review of facility policy titled "Handling of Patient/Guest Complaints and Grievances," dated September 2021 showed the following inofmration:

POLICY
It is the policy of SLSL to formally receive, review, and respond to Complaints and/or Grievances from patients or patients ' representatives, their family members, and guests of SLSL.

3. Management of Grievances

a. In the event that the Complaint cannot be resolved in a timely manner through the process described in Management of Complaints, or meets the definition of a Grievance, the patient and/or their representative may submit a verbal or written Grievance by use of any of the following mechanisms:...

b. Following receipt of a written or verbal Grievance, the hospital 's Patient Advocate or designee reviews, documents, and coordinates the investigation of the Grievance.

c. The documented Grievance, along with other available documentation, is forwarded to the involved department leader or designee for investigation. Any Grievance that places the patient in immediate danger or has the potential for patient harm is investigated immediately.

d. The Patient Advocate or designee, under the direction of the Grievance Committee, responds to the Grievance with written notice to the patient or theirrepresentative within seven (7) business days of receipt of the Grievance. The notice is provided in a language and manner the patient or patient's representative.

e. The Patient Advocate or designee may attempt to contact the Complainant by telephone if more information is needed to investigate the Complaint or Grievance. If unable to reach the Complainant by telephone, the Patient Advocate will send a letter to the Complainant requesting a return phone call. If the Complainant does not respond within 7 days of such a letter, the case will be investigated to the extent possible in accordance with this policy and procedure.

f. If the Grievance is not able to be resolved within seven (7) business days, a written acknowledgement, sent by the 7th business day, shall inform the patient or the 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. If the hospital is still working to resolve an extensive Grievance, the hospital will follow up with a written response every 30 business days until the investigation is resolved. Every reasonable attempt will be made to close cases within 30 business days.

g. In its 30 business day written response, the hospital is not required to provide an exhaustive explanation of every action the hospital has taken to investigate the Grievance, or to resolve the Grievance, or other actions taken by the hospital.

h. In its 30 business day written response, the hospital is not required to include statements that could be used in a legal action against the hospital, but provides adequate information to address:
i. The name of the hospital contact person;
ii. The steps taken on behalf of the patient or patient ' s representative to investigate the Grievance;
iii. The results of the Grievance process; and
iv. The date of completion is the date of the letter.
i. When a patient or patient ' s representative communicates a Grievance to the hospital via email, the hospital may provide its response via email pursuant to hospital policy. If the patient or patient ' s representative requests a response via email, the hospital may respond via email. When the email response contains the information stated in this requirement, the email meets the requirement for a written response.

k. Documentation of Grievance resolution efforts is maintained by the organization.

4. Referrals

a. Refer quality of care issues to utilization review, quality management, risk management, or peer review functions as appropriate.

5. Data collected regarding patient Grievances, as well as other Complaints that are not defined as Grievances (as determined by the hospital), is incorporated in the hospital's Quality Improvement Program.


Review of grievance for patient (ID#1) was received regarding the care and services provided to the patient in the emergency department on 4/19/2023. Grievance investigation performed by Director of Patient care services (ID 51) shows comments of deferring to Emergency Department Medical Director (ID #56) for review of medical services provided. The facility could not provide evidence of medical review and the grivance was closed.


Interview with Emergency Department Medical Director (ID #56) on 8/23/23 at 1:25 PM. She stated that she does not have access to document in the system used for complaints and griveances. She went on to say that she did not remeber reviewing or specific details for the care of patient (ID#1).