HospitalInspections.org

Based on review of facility documents, and staff interviews (EMP), it was determined the facility failed to follow adopted policies ensuring that complainants received a final resolution letter containing all required elements for two of four complaints reviewed.

Findings include:

Review of "Patient Grievance & Handling Customer Complaints" revised 1/12, revealed " ... a grievance is defined as an allegation involving a violation of a patient's rights, an allegation of premature discharge or any complaint that cannot be promptly resolved by staff present. A patient grievance would also include situations where patients or the patient's representative call or write to the hospital about concerns related to care or services that were not resolved during their stay or who did not wish to address their issue during their stay. Additionally, if a patient or patient's representative requests their complaint be handled as a formal complaint or grievance, then all requirements related to grievances apply. ... For the purposes of this policy, a complaint is defined as any concern or issue that a patient or a patient representative may have regarding a patient's care or treatment that does not involve a violation of a patient's rights or an allegation of premature discharge. A complaint would be able to be resolved by staff and/or a department manager in a timely manner ....2. Patients and their family members are informed of the patient's rights and responsibilities upon admission, and the process by which they can voice any concerns related to their rights and/or treatment ... 10. Once the concern has been resolved, the Patient Advocated or designee will provide a written response within 7 days of the grievance being received. The response will include: a) The name of the contact person b) The steps taken to investigate the grievance on behalf of the patient c) The results of the grievance process, how the grievance was resolved; d) The process to follow if the patient/complainant is not satisfied with the response ... ."

1) A review of sample of four complaints were reviewed. During the review of documents, it was noted that two of the written resolution responses to the complainants did not contain all elements as described in the facility's policy.
2) Interview with EMP5 on August 9, 2012, at approximately 2:50 PM, confirmed that the written responses did not contain all required elements described in the facility's policy.