HospitalInspections.org

Based on document/record review and staff interview it was determined the CAH failed to ensure policies for complaint reporting and resolution were followed. Potentially, affecting all patients receiving services.

Findings include:

1. The CAH policy effective date 9/30/2003, titled, "Patient & Families Right to Present Complaints" was reviewed on 9/26/16 at 3:00 PM. The policy under "V. PROCEDURES 5. When a grievant is identifiable an explanation of the resolution or disposition of the grievance shall be provided to the grievant and the written report shall be kept on file in the Social Services Department".

2. A request for "Complaint Log" was made on 9/26/16 at 10:00 AM. On 9/27/16 at 10:00 AM, an untitled, handwritten log of complaints was reviewed. The log indicated 18 complaints dating from 2/19/13-7/11/16. A complaint was written on 9/25/16, but was missing information about the nature of complaint or resolution.

3. The "Patient Complaint Report" was reviewed on 9/27/16 at 1:30 PM. There was no documentation of the date of resolution.

3. On 9/27/16 at 10:15 AM, an interview was conducted with the Director of Social Services (E#10). E#10 explained that supervisors, administration or Social Services can take a complaint and complete form. These should be forwarded to me to log, follow-up and resolve. E#10 stated, "I was not aware of this complaint until today".

4. On 9/27/16 at 1:30 PM, an interview was conducted with the Administrator (E#1). E#1 was asked if the complaint was resolved. E#1 replied, "I dropped the ball on this, I didn't follow-up or give to Social Services."