HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #3) grievances reviewed, the Hospital failed to ensure that the timeline for a written response for Pt. #3's grievance was followed.

Findings include:

1. On 5/25/2021, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted to the Hospital on 5/11/2021 due to complaint of shortness of breath.

2. On 5/26/2021, Pt. #3's grievance dated 5/13/2021 was reviewed and included, " ... Details of the affected person: (Pt. #3)... Classification: Grievance... What is this issue about? Care provided ... Feedback Categories: Care/Treatment ... Diversity and Inclusion ..."

3. On 5/26/2021, a letter dated 5/24/2021 to Pt. #3 included, "Dear (Name of Pt. #3), I am writing to you today to follow-up on the concerns that you shared ... Please (accept) my apology for any distress or frustration you experienced due to the situation you described. Please know that we take your concerns very seriously and plan to use this experience to improve the quality of care and service we provide. Your concerns were brought to the attention of the appropriate leadership ... Sincerely ... Patients Relations Coordinator ..."

4. On 5/26/2021, the Hospital's policy titled, " Patient Complaint and Grievance Management" (effective 8/2020) included " ...IV ... Patient Grievance ... Grievances includes complaints of unlawful discrimination on the basis of age, race, color, national origin, religion, culture ... V ... Grievance Resolution: 1. Grievance level concerns should have written communication to the patient regarding resolution ... a ... If a resolution cannot be communicated within seven calendar days form the date it was initially reported, patient relations will coordinate: acknowledgement to the patient that the grievance is under review, and the date frame in which the patient can expect a written response ..."

5. On 5/26/2021 at approximately 11:30 AM, an interview was conducted with E #17 (Patient Relations Manager). According to E #17, Pt. #3's event was considered as a grievance and was initiated on 5/13/2021. E #17 stated that whether the case is under investigation or has been resolved, a communication letter should be sent to the patient within seven days from the initiation date of the grievance. E #17 stated that the letter should have been sent on 5/20/2021.