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Based on review of grievances and facility policy, and staff interview it was determined the facility failed to provide a written response which included all the results of the grievance process for 3 of 4 patients (#2, #5 and #6) and/or family members who filed grievances related to patient injury and who had been referred to Risk Management. This failure resulted in a lack of clarity and closure regarding the resolution of the grievance and had the potential to interfere with patient/family understanding and satisfaction. Findings include:

The hospital's grievance policy, "CONCERN AND GRIEVANCE MANAGEMENT PROGRAM," dated 9/85, and reviewed 9/04, stated "The complainant and/or family, as appropriate, will receive an indication of how the investigation will be conducted and who the contact person will be during the investigation. The issues will then be forwarded to the appropriate division/department(s) director/manager(s) who will ensure that an investigation is completed and appropriate action is taken, with the goal of completing the (grievance) process within one week."

The grievance policy described multiple options for a patient or family member to enter a concern, complaint, or grievance. One such method was by phone, called "Patient Concern Line" (PCL), which was triaged by the Patient Relations Coordinator.

In an interview on 8/03/10 at 1:55 PM, the Patient Relations Coordinator stated her department documented patient and family contact from the point of complaint or grievance through to closure using a software program called "i-Sight." The i-Sight document would indicate the status of the case, which would include documentation of the dates created, assigned, confirmed, and closed. She further explained that when her department referred a case to Risk Management, an incident report would then be generated in another software system called QSTATIM Incident Manager, and the i-Sight record was then closed by Patient Relations.

In an interview on 8/03/10 at 2:35 PM the Risk Management Specialist stated upon receipt of a referral, her department would follow the grievance through to resolution as per the written policy. The Risk Management Specialist stated her department utilized a different software program from the Patient Relations department. She said the two different programs did not interface with one another, and her department relied upon a software program "QSTATIM Incident Manager" to identify if the referral was due to patient injury or a grievance.

In the following examples, patients/family members did not receive written responses from the hospital related to their grievances.

1. A call to the PCL on 6/10/10 by a family member of Patient #2 was documented in i-Sight. The family member had stated Patient #2 had fallen out of bed after the use of a sitter had been discontinued. The document indicated the case had been determined to be a grievance, and triaged to Risk Management. Closure for the i-Sight document was 6/11/10 at 11:05 AM. A QSTATIM Incident Manager incident report, opened on 6/11/10 at 11:04 AM, identified the incident as a fall. In the "Incident Description" section of the report, there was an e-mail describing the PCL grievance from the family member of Patient #2. There was no evidence the family member of Patient #2 had been informed in writing of the grievance investigation or outcome.

In an interview on 8/03/10 at 2:45 PM, the Risk Management Specialist stated the QSTATIM Incident Manager report had identified the incident as a fall, rather than a grievance. She stated the investigation for the fall had been completed 7/20/10. The Risk Management Specialist stated she had not contacted the family of Patient #2 or followed up with a written response.

2. A call to the PCL on 5/18/10 by a family member of Patient #6 was documented in i-Sight. A family member had called with a complaint that Patient #6 had been scheduled to be discharged home, but the discharge would be postponed. Patient #6's IV had disconnected and he experienced a large blood loss as a result, requiring multiple transfusions. The document indicated the grievance filed by Patient #6's family member had been determined to be a grievance, and had been triaged to Risk Management. Closure for the i-Sight document was 5/18/10 at 4:39 PM. A QSTATIM Incident Manager report, opened on 5/18/10 at 4:38 PM, identified the incident as "Patient Care." In the "Incident Description" of the report was a note describing the PCL grievance initiated by the family member of Patient #6. There was no evidence the son of Patient #6 had been informed in writing of the grievance investigation or outcome.

In an interview on 8/03/10 at 3:00 PM, the Risk Management Specialist stated the incident report had identified the incident as patient care related, rather than a grievance. The Risk Management Specialist stated she had not contacted the family of Patient #6 or followed up with a written response.

3. A call to the PCL on 5/26/10 by the mother of Patient #8 was documented in i-Sight. The mother called with a complaint that Patient #8 had contracted a MRSA infection during his hospitalization. Patient #8 had previously tested negative for this infection. The document indicated the case had been determined to be a grievance, and triaged to Risk Management. Closure for the i-Sight document was on 5/26/10 at 11:50 AM. A QSTATIM Incident Manager report, opened on 5/26/10 at 11:42 AM, identified the incident as "Patient Care." In the "Incident Description" of the report was a note describing the PCL grievance phone call with the family member of Patient #8. There was no evidence the family member of Patient #8 had been informed in writing of the grievance investigation or outcome.

In an interview on 8/03/10 at 3:10 PM, the Risk Management Specialist stated the incident report had identified the incident as patient care related, rather than a grievance. The Risk Management Specialist stated the NICU Manager, Physician, and Infection Control Nurse had met with a family member of Patient #8, and she felt the issue had been resolved. The Risk Management Specialist reviewed the incident report and confirmed the grievance had not been followed up with a written response.

The hospital failed to investigate, resolve, and respond to complainants in writing.