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820 E MOUNTAIN VIEW STREET

BARSTOW, CA 92311

PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION

Tag No.: A0123

Based on interview and document reviews, the hospital failed to ensure that its grievance process resolution letters included the date that the grievance processes were completed. This failure created a risk for patients and/or families that submitted grievances to the hospital to be dissatisfied with the actions taken on their behalf to resolve their grievances in a universe of 11 patients.

Findings:

On October 29, 2013, a review of Patient 1's grievance submitted by the patient's family member related to quality of care and billing concerns was conducted.

The resolution letter did not contain the date that the hospital resolved Patient 1's grievance.

On October 29, 2013 at 11:50 AM, an interview was conducted with the hospital's Chief Quality Officer (CQO). The CQO reviewed Patient 1's grievance process resolution letter. She acknowledged and confirmed that the letter did not include the grievance process resolution completion date. The CQO stated that it had not been the hospital's practice to include the grievance process resolution completion date in the resolution letters. She stated that according to the regulation and the hospital's policy and procedure, all grievance process resolution letters should include the date that the grievance processes were completed.

A review, on October 29, 2013, of the hospital's policy and procedure (P&P), titled, "Patient/Family Grievances/Complaints," dated September 23, 2013 was conducted. The P&P included the following:

"The Chief Executive Officer is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."