HospitalInspections.org

Based on interview and record review, the hospital failed to provide a written letter of response of the resolution of the grievance, citing 1 of 5 patients (Patient #1) who lodged grievances from 02/08/17 through 06/01/17.

Findings included:

Patient #1 was admitted on 04/26/17 for "acute respiratory failure." The hospital received a grievance on 05/02/17. A letter of response acknowledging the receipt of grievance was sent on the same day. In the response letter, the hospital indicated a follow-up letter was going to be sent. The surveyor was in the hospital on 06/08/17 (27th business day after the grievance was received) and the follow-up letter about the resolution of the grievance was not sent. The hospital policy required a follow-up letter on or before 21 business days of the initial receipt of the grievance.

In an interview on 06/07/17 and 06/0817 at 12:42 PM and 11:00 AM respectively, Personnel #3 confirmed she sent a letter of response on 05/02/17 acknowledging the receipt of the grievance and did not send a follow-up letter as required.

Policy # RI.1.90 "Patient Grievance and Complaint Management" revised 10/2013 required "C. Grievance Resolution Process ...If a grievance will not be resolved ...within 7 days, the complainant should be informed ...that the facility is still working to resolve the grievance ...will follow-up with a written response within 21 business days of initial receipt of grievance."