HospitalInspections.org

Based on hospital grievance log review, policy and procedure review, and staff interview the hospital failed to provide a written notice of the hospital's decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for each grievance submitted to the hospital.

Findings:

1. On the morning of 12/04/2015, surveyors reviewed the hospital's grievance policy. The policy titled, "Grievance Committee," documented, "...the Risk Manager is responsible for completing and sending a letter to the patient or their representative. The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to resolve the grievance, the results of the grievance process, and the date of completion..."

2. On the morning of 12/04/2015, surveyors reviewed a document titled, "Grievance Log." The document was blank.

3. On the morning of 12/04/2015, surveyors reviewed a document titled, "PR Comp and Grievances - All" The document contained 5 patient complaints/grievances. Two of the five (#4 & #11) complaints/grievances that involved patient care issues were not provided a letter that contained notice of the hospital's decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for each grievance submitted.

4. On the morning of 12/04/2015, surveyors interviewed the Risk Manager. The Risk Manager told surveyors that he had not sent a letter to patient #4 and patient #11 in response to the grievances submitted.