HospitalInspections.org

Based on record review and interview, the facility failed to follow specifed timeframes for review of the grievance and the provision of a response for 1 (SP#2) of 6 sampled patients.

The findings include:

1. Review of communications between facility and SP#2 ' s family on 04/05/10 @ 1030 revealed that SP#2 ' s daughter sent her first grievance letter stating her complaints to the facility on 10/18/09.

2. During an interview with the Manager of Risk Management on 04/05/10 @ 1200, the manager said that the facility never received the first letter sent to the facility.

3. A copy of the email sent to the CEO by the AVP of Patient Services on November 17, 2009 @ 1433 showed, " I just read this letter (second letter from complainant). I never received the letter (first letter) that was addressed to me (AVP of Patient Services). I called the complainant and left her a message on her cell to call me. I will inform her that we are looking into this " . There was no evidence to show that the AVP of Patient Services was successful in contacting the complainant.

4. In the second complainant letter to the facility dated November 13, 2009, showed " To my great consternation, I have yet to receive any sort of response, either by phone or in writing. This strikes me as further confirmation of your hospital ' s unwillingness to communicate in a constructive, timely and problem-solving manner with families (my father being demented and unable to speak for himself). Even an acknowledgment of receiving the letter would be more polite than silence. Open communication is widely understood to reduce conflict. I do hope to hear from you. I appreciate any thoughts you may have on these matters " .

5. Review of the response letter that the facility sent to complainant dated December 7, 2009 (20 days after receiving the second letter), showed the CEO wrote: " I have forwarded your concerns to the attention of the facility ' s Risk Manager who will investigate and then contact you to follow up on your concerns " .

6. Review of the facility ' s Policies and Procedure on Patient Concerns/Grievance on 04/05/2010 @ 1500, the policy states, " The complainant will receive either a verbal or personal acknowledgment from the Director/designee, as soon as possible, or, at a minimum, within two (2) business days. The Director or the designee must make at least two (2) attempts to reach the complainant. The dates and times of the attempts must be documented in the " Manager ' s Additional Notes " of the Risk Management Module. Written grievances shall be acknowledged using the same timeframe. A copy of this letter will be forwarded to the Risk Manager when sent to the complainant. Following the investigation, all written concerns will be followed-up with a written letter from the facility. Occasionally a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days. The Risk Management will maintain a Grievance Log, tracking closure of the grievance and ensuring timetables are observed " .

7. During an interview with the Risk Manager on 04/05/10 @ 1030, the manager said, " The AVP had contacted the complainant two times and I have attempted to call her three times but she has not called us back " . The manager further confirmed that those calls and attempts to contact the complainant were not documented anywhere and that there was no written communication sent to the complainant as to the outcome of the investigation as promised by the CEO.

8. Review of Patient Grievance Log on 04/05/10 @ 1515 revealed that this particular complaint was recorded as " closed " on December 7, 2009, the date when the response to the complainant was sent by the CEO. There was no documentation if the complainant was contacted (date and time) to inform the outcome of the investigation before the case was closed without resolution.