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Based on staff interviews and review of 20 patient complaint records, medical records, policies, procedures, and other pertinent documentation, it was determined that the hospital failed to ensure an effective process for prompt resolution of complaints and grievances as evidenced by:

A review of the hospital's complaint and grievance process revealed that:
Complaints are often not referred to the appropriate office in a timely manner for investigation and prompt resolution;
Complaints forwarded to units for investigation are not tracked to ensure resolution; and,
The hospital refuses to accept all telephone and some written complaints received in the medical staff office, which frustrates attempts by patients and family members to lodge a complaint against any physician.

(1) Based on interviews with staff members and review of 20 complaints, it was determined that complaints come to the Outcomes Management Office from multiple sources. It was substantiated that when a written complaint is sent directly to a unit or to the hospital business office, these complaints are often not forwarded in a timely manner to Outcomes Management for investigation. This results in a failure to complete investigations in a timely manner in accordance with the regulatory requirement and with hospital policy. For example, complaint # 2 was received by the business office on 11/28/2009 but not forwarded to the Outcomes Management Office for review and investigation until 12/22/2009 and complaint #15 was received by the Business Office on 11/12/2009 and was not forwarded for more than 6 weeks to the Outcomes Management Office on 12/28/2009.

(2) Based on interviews with staff and review of complaint documentation, when a complaint does reach the Outcomes Management Office it is sometimes forwarded to the VPMA or to hospital unit representatives for investigation. However, after forwarding complaints to units for investigation, in 16 of 20 complaints reviewed, there was no tracking or follow-up completed to ensure prompt resolution of each complaint.

For example, complaint #12 alleged discharge planning concerns regarding patient #12. This complaint was referred to the VPMA and it was scanned into the credential file for the physician. However, no follow up or investigation was found documented as completed; no communications were ever sent to the complainant; and no follow-up communication between Medical Staff and Outcomes Management was found completed or documented.

(3) Interview with the Medical Staff Secretary revealed that when the Medical Staff Office receives complaints by telephone, they refuse to accept them and tell the complainant that complaints are only accepted if they are put in writing. No tracking of these reported telephone complaints is completed. The Secretary reported that often when complainants are told that telephone complaints will not be accepted or considered, the complainants often do not follow up with any written complaint, and therefore, those concerns are not ever recorded or investigated.

Also, based on interviews with staff members, it was determined that many written physician related complaints are forwarded from the Outcomes Management Office to the VPMA (Vice President for Medical Affairs). In an interview on 01/08/2009, the VPMA reported that if he speaks to a complainant and the matter involves quality of care concerns, he often tells them they need to refer the matter to the hospitals' physician board. The VPMA also reported (as did the Office Secretary) that if a complainant telephones the medical staff office they are told that the hospital will not accept complaints regarding physicians unless they are in writing. The VPMA reported to the surveyor that it would be inappropriate to confront a physician on the basis of a complaint that was not in writing. Therefore, a complainant may be told by the Medical Staff Secretary that their complaint will not be accepted unless in writing, and then after it is placed in writing, the complainant may be told to take the complaint to yet another Board.

Further examples of barriers to attempts to file complaints against physicians, complainant (#10) was told that the hospital would not disclose any outcome of any investigation because the content of the complaint was a peer-review matter. The complainant chose at that point to not pursue the complaint. However, review by the surveyor revealed that as of the date of the survey, the matter was in fact not sent for peer-review by the hospital or investigated.

In sum, the hospital failed to have a clearly understandable process for patients and family members to follow to file a complaint and actively frustrated attempts to file complaints through the Medical Staff office.

Based on staff interviews and review of patient complaints, medical records, policies, procedures and other pertinent documentation, the hospital failed to ensure an effective procedure for the submission of written or verbal grievances and the hospital's governing body failed to ensure the same. Importantly, the hospital does not provide patients with clearly understandable process to file a complaint. See Tag A-0118.

Based on staff interviews and review of patient complaints, medical records, policies, procedures, and other pertinent documentation, the hospital failed to ensure timely review of grievances and responses.

Through the review of 20 complaints and interviews with staff it was revealed that complaints come to the Outcomes Management Office from multiple sources. Records indicated that, if a written complaint is sent directly to a unit or to the hospital business office, the complaints are often not forwarded in a timely manner to Outcomes Management for investigation. This results in a failure to complete investigations in a timely manner in accordance with both hospital policy and Federal requirements for prompt resolution of complaints. For example:

1. Complaint # 2 was received by the business office on 11/28/2009 but not forwarded to the Outcomes Management Office for review and investigation until 12/22/2009.

2. Complaint #15 was received by the Business Office on 11/12/2009 and was not forwarded for more than 6 weeks to the Outcomes Management Office on 12/28/2009.

In 20 of 20 complaints reviewed, the hospital failed to provide the complainant with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Hospital staff reported to the surveyor that they do not respond to complainants in writing even when investigations are conducted. Also, in interview on 01/08/2010, the VPMA reported that most complaints regarding physicians are not investigated. He reported that " he-said-she-said complaints can't be proven anyway" and quality of care concerns are peer protected and therefore no information resulting from any investigation would ever be shared with patients.

In follow up interview on 01/11/2010 the VPMA did report that the hospital does take every complaint very seriously. Nonetheless, review of 20 grievance and complaint records, confirmed the failure to ever provide complainants with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Some examples include:

1. Complaint #15 was filed on 11/12/2009 and alleged that the complainant was misdiagnosed, that pain treatment was inappropriate, and that the physician was rude, impolite, cold, and very uncaring. The complaint was referred for physician follow-up. The only follow up found documented, was a single phone call placed by a physician that went to a number with no answer and a note that the physician would try again. There was no written communication with the complainant and no documented evidence of an investigation of the complaint.

2. Complaint #16 indicated that a patient reported concerns with quality of care. She indicated that the physicians were not listening to her and she was to be discharged but no-one had given her any discharge information. She reported that one physician asked her if she was just drug seeking and another stated he had patients who were really sick and needed his help. Review of the medical record did not substantiate the allegations, however, pertinent documentation indicated that this physician related complaint was not referred, investigated or follow-up on at all.

3. Complaint #17 indicated that a patient was provided with a discharge plan that included referral for follow up with a particular physician practice. However, it was alleged that when the patient contacted that practice after discharge they were told that that physician does not see patients. This complaint was referred to the VPMA, but no documented evidence was found that the content of the complaint was investigated or appropriate follow up was performed. There was no documentation of communication back to outcomes management, and no communication with the complainant was documented.

4. Complaint #14 included significant allegations. This complaint was from a forwarded e-mail written by the nursing Supervisor. The Supervisor indicated that the patient's mother alleged that patients were being seen in the hallways outside of radiology and that confidential health information was being discussed and disclosed. It was alleged that staff were discussing patient's conditions, what was wrong with them, and their plans of care. The Supervisor provided the patient a room and tried to expedite her MRI but the patient and their mother left AMA (against medical advice). Although, the Supervisor reported the concern in writing, no evidence was found that the hospital staff investigated further or contacted the complainant who the Nursing Supervisor tried to assist.

5. Complaint #10 filed on 08/31/2009 alleged that a surgeon changed an already signed consent form (signed by patient #10) to reflect a procedure that the patient had not consented to. The complainant was told by hospital staff that even if investigated, her concerns were peer protected and the hospital would therefore not report any findings back to her. The complainant therefore did not submit information for investigation, and subsequent to that decision by the complainant, the hospital did not forward the matter for peer-review.