HospitalInspections.org

Based on staff interview and document review, it was determined the hospital failed to ensure it provided each patient who had filed a grievance with written notice of its decision related to the resolution of the grievance. Specifically, the hospital failed to provide the results of the grievance process to the patient in one (1) of four (4) grievances reviewed in the survey sample (Grievance #2).

Findings:

Four (4) grievances submitted to the hospital from December 2023 to present were reviewed on 03/26/24. A response from the hospital to Grievance #2 was dated January 23, 2024 and read in part, "Your concerns were escalated to our Chief Medical Officer, who has since initiated further review. Although the findings of this review will not be shared, we have the utmost confidence that this additional review will be productive, and lead to action and recommendations to resolve the issues." The letter contained no additional information related to the results of the grievance process.

An interview was conducted with Staff Member #1 on 03/26/24. Staff Member #1 advised that some of the staff members in the patient advocacy department writing the response letters are new and may not be familiar with what needs to be included in a response letter. Staff Member #1 confirmed the letter should contain a resolution of the grievance.

The facility's procedure, Complaints and grievances was reviewed and reads in part: Final response letter must include the following four (4) required elements according to CMS CoP (Centers for Medicare and Medicaid Services Conditions of Participation) 482.13 (a)(2)(ii): Organization Contact Person, Steps Taken to Investigate, Results of the Grievance Process, Date of Completion.