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Based on record review and interview, the facility failed to classify unresolved concerns as grievances for three (#15, #16, #17) patients. A total of seven grievance files and one incident report were reviewed. The facility census was 466.

Findings included:

1. Record review of the facility's policy titled, "Patient Concern/Grievance Policy" dated 02/16/10, showed the following direction:
- Patient concerns, which cannot be resolved at the point of service, will be tracked, reported and addressed;
- Every reasonable effort will be made by Health System co-workers/leaders to resolve patient concerns at the point or time of service. Any concern expressed by a patient or their representative will be reviewed, resolved and documented.
- Patient concerns that are unable to be resolved at the point or time of service will be considered grievances and will be resolved as follows:
Patient Relations will assign a level of concern and forward to the appropriate area. Directors/Managers will investigate the grievance, facilitate a written resolution within the specified timeframes and document the response, copying Patient Relations and all other involved areas.
- A written response will be sent to the patient or his representative within seven business days of receipt of the complaint. Written responses will include: name of system/facility contact person, steps taken on behalf of the patient to investigate the concern, findings from the review, resolution of the complaint and date of resolution.
- If resolution cannot be made within seven business days an initial letter will be sent indicating the estimated time needed to resolve the complaint, but should be no more than 60 business days.
- If the person initiating the grievance is not satisfied with the response received, he/she may appeal to the Patient Relations Department. Individuals using the appeal process will be asked to specify the concern and desired remedy for consideration by the appropriate Vice President, Clinical Service, or designee.
- Individuals remaining dissatisfied after the first appeal may file an appeal to the Health System Grievance Committee.

2. Review of the facility's incident report log showed a statement received by the facility on 12/21/10 from discharged Patient #15's family member. The statement was that his/her spouse acquired a septic (infection in the blood stream) while in the hospital that led to his/her death. The family member was quoted as saying, "Hospital killed (his/her) (husband/wife)". Review of the facility's comments regarding this incident showed that on 12/27/10, it was not classified as a grievance.

During an interview on 03/03/11 at approximately 10:00 AM, Staff C, Director of Patient Safety, Service and Risk Management stated that this incident was not considered a grievance.

During an interview on 03/03/11 at approximately 10:00 AM, Staff A, Physician/Senior Vice President of Clinical Excellence, agreed that the statement from Patient #15's family should have been considered a grievance.

3. Review of a complaint received by the facility on 01/19/11 showed a Patient Satisfaction survey with hand-written comments made by the complainant, discharged Patient #16. The comments included numerous care issues, including physical therapy, pain medication administration, and IV (intravenous - small catheter inserted into a vein for administering medications and fluid) insertion. The complainant also wrote that the departments did not communicate with each other. The complainant wrote that he/she had a terrible stay and that the (spouse) felt as though they could not leave the patient alone. The patient wrote their name and phone number on the Patient Satisfaction survey. The facility classified the complaint as a "Care Provider Issue", specifically, "Provider Communication Issue", and this was not considered a grievance.

During an interview on 03/03/11 at 9:25 AM, Staff E, Senior Vice President/Chief Operating Officer, stated that the information received from discharged Patient #16 definitely should have been called a grievance.

4. Review of a document identified as feedback ticket HUG766076 (Patient #17) indicated that a patient's family reported on 01/8/11 that they had an issue with the care of Patient #17. The family reported that they did not want Patient #17 to receive morphine. The morphine had been ordered by the physician and administered by the nurse after the family indicated that they had reported to the emergency department and to the ordering physician that they did not want this medication administered and had suggested acceptable alternatives.
The section of the document titled "Resolution Expectation" included a comment by facility staff which read: you will not be able to resolve this. Unable to even carry on conversation with family. The preferred resolution method stated that a letter was the preferred contact method. On the form the question, "Is this the final resolution?" was documented as "Yes", dated 1/10/11.
Further notes on this issue indicated that the family took the patient home after this incident leaving the hospital against medical advice (AMA).
There is no response either verbal or written included with the resolution by the facility. On the grievances and complaints list this is indicated as not being a grievance.

5. During an interview on 03/02/11 at 11:25 AM, Staff C, Director of Patient Safety, Service, Risk Management, stated that the "point of service" reference in the facility's policy is considered to be the inpatient stay, not interpreted as at that point in time.

6. During an interview on 03/02/11 at 3:10 PM, Staff C stated that the timeframe for investigation and response is the same for complaints and grievances. Staff C stated that they address concerns at the lowest level. Staff C stated that after a letter is sent to the complainant, the complainant can appeal. If the complainant appeals, then it goes to the grievance committee. If the complainant does not appeal, it does not go to the grievance committee. Staff C stated that a letter is sent if the issue is a complaint or a grievance.

7. During an interview on 03/03/11 at 9:25 AM, Staff E, Senior Vice President/Chief Operating Officer, stated that they try to resolve issues immediately. Once a concern goes past that point in time, it is taken up the chain of command, to the grievance committee. Staff E stated that not every grievance goes to the committee. If a grievance is resolved at a lower level, it doesn't go to the committee. Staff E stated that issues are treated as a grievance but they try to do service recovery, which is immediate. If it goes on past that, it's a grievance.

Based on record review and interview, the facility failed to provide written notice to patients or their representatives explaining the delay in resolving a grievance and an approximate resolution timeframe for three (#15, #16, #17) patients. The facility failed to provide a written response including the name of the facility contact person, the steps taken to resolve the grievance, the resolution and the date of completion for three (#15, #16, #17) patients. A total of seven grievance files and one incident report were reviewed. The facility census was 466.

Findings included:

1. Record review of the facility's policy titled, "Patient Concern/Grievance Policy" dated 02/16/10, showed the following direction:
- Patient concerns, which cannot be resolved at the point of service, will be tracked, reported and addressed;
- Every reasonable effort will be made by Health System co-workers/leaders to resolve patient concerns at the point or time of service. Any concern expressed by a patient or their representative will be reviewed, resolved and documented.
- Patient concerns that are unable to be resolved at the point or time of service will be considered grievances and will be resolved as follows:
Patient Relations will assign a level of concern and forward to the appropriate area. Directors/Managers will investigate the grievance, facilitate a written resolution within the specified timeframes and document the response, copying Patient Relations and all other involved areas.
- A written response will be sent to the patient or his representative within seven business days of receipt of the complaint. Written responses will include: name of system/facility contact person, steps taken on behalf of the patient to investigate the concern, findings from the review, resolution of the complaint and date of resolution.
- If resolution cannot be made within seven business days an initial letter will be sent indicating the estimated time needed to resolve the complaint, but should be no more than 60 business days.
- If the person initiating the grievance is not satisfied with the response received, he/she may appeal to the Patient Relations Department. Individuals using the appeal process will be asked to specify the concern and desired remedy for consideration by the appropriate Vice President, Clinical Service, or designee.
- Individuals remaining dissatisfied after the first appeal may file an appeal to the Health System Grievance Committee.

2. Review of the facility's incident report log showed a statement received by the facility on 12/21/10 from discharged Patient #15's family member. The statement was that his/her spouse acquired a septic (infection in the blood stream) while in the hospital that led to his/her death. The family member was quoted as saying, "Hospital killed (his/her) (husband/wife)". The facility sent a letter to the family member on 12/30/10 asking him/her to reply in detail with concerns. The letter stated that upon receipt of their written concerns, the facility would conduct a thorough clinical review, but to allow 30-60 days for completion. Review of the facility's comments regarding this incident showed that on 12/27/10, this incident was not classified as a grievance. No follow-up letter was sent to the complainant.

During an interview on 03/03/11 at approximately 10:00 AM, Staff C, Director of Patient Safety, Service and Risk Management stated that this incident was not considered a grievance. Staff C stated that they focused on the clinical aspect, but it was a difficult family situation, another family member wanted billing assistance, so the family was referred to the billing department. Staff C confirmed no follow-up letter was sent to the complainant.

During an interview on 03/03/11 at approximately 10:00 AM, Staff A, Physician/Senior Vice President of Clinical Excellence, agreed that the statement from Patient #15's family should have been considered a grievance.

3. Review of a complaint received by the facility on 01/19/11 showed a Patient Satisfaction survey with hand-written comments made by the complainant, discharged Patient #16. The comments included numerous care issues, including physical therapy, pain medication administration, and IV (intravenous - small catheter inserted into a vein for administering medications and fluid) insertion. The complainant also wrote that the departments did not communicate with each other. The complainant wrote that he/she had a terrible stay and that the (spouse) felt as though they could not leave the patient alone. Patient #16 wrote their name and phone number on the Patient Satisfaction survey. The facility classified the complaint as a "Care Provider Issue", specifically, "Provider Communication Issue", and it was not considered a grievance. On the facility's intake form, a section that stated, "Is the (complainant) to be contacted regarding resolution", was marked, "Yes". A letter was sent to complainant on 01/19/11 thanking them for the returned patient satisfaction survey and stated that the comments regarding their care would be forwarded to the appropriate department leader for review and follow up with staff. The letter did not explain the delay in resolving the grievance and an approximate resolution timeframe. No follow-up letter was sent to the patient to show investigation findings.

During an interview on 03/03/11 at 9:25 AM, Staff E, Senior Vice President/Chief Operating Officer, stated that the information received from discharged Patient #16 definitely should have been called a grievance and followed up with a letter sent to the patient.

4. Review of a document identified as feedback ticket HUG766076 (Patient #17) indicated that a patient's family reported on 1/8/11 that they had an issue with the care of the patient. The family reported that they did not want the patient to receive morphine. The morphine had been ordered by the physician and administered by the nurse after the family indicated that they had reported to the emergency department and to the ordering physician that they did not want this medication administered and had suggested acceptable alternatives.
The section of the document titled "Resolution Expectation" included a comment by a staff person which read: you will not be able to resolve this. Unable to even carry on conversation with family. The preferred resolution method stated that a letter was the preferred contact method. On the form the question, "Is this the final resolution?" was documented as "Yes", dated 1/10/11.
Further notes on this issue indicated that the family took the patient home after this incident leaving the hospital against medical advice (AMA).
There is no response either verbal or written included with the resolution by the facility. On the grievances and complaints list this is indicated as not being a grievance.