HospitalInspections.org

A. Based on review of Hospital policy, "Patient Relations Worksheet" grievance review, and staff interview, it was determined, that for 1 of 1 Patient (Pt. #1) who complained of not receiving a medical screening in the Emergency Department (ED), the Hospital failed to ensure a written notice of grievance investigation findings were provided to the patient.

Findings include:

1. Hospital policy titled: "Complaints/Grievances" was reviewed on 6/2/10 at 2:00 PM. The policy required: "Grievance... The grievance will be entered in the database and a copy will be sent to the Manager of the Department(s) involved with a response form. The Manager will investigate, address with staff, and return response within 14 days. The response will be conveyed to the complainant in writing or by phone..."

2. On 6/2/10 at 12:30 PM, a Patient Relations Worksheet dated 5/17/10 was reviewed. The worksheet included a complaint that Pt. #1 had phoned to the Hospital Patient Care Advocate (PCA) regarding Pt. #1 not being registered, triaged or examined in the ED on 4/29/10, with complaint of anxiety. The worksheet included: "I told her [Pt. #1] I would investigate her complaint ... I would forward her complaint to the mgr of our registration staff ..." No documentation from the Registration Manager's investigation was found. No further response was provided to Pt. #1 regarding the grievance investigation or disposition.

3. On 6/2/10 at 12:55 PM, an interview was conducted with the PCA. The PCA stated that follow-up with Pt. #1 did not occur because a clinical record was not generated for an ED visit and Pt. #1 hung up abruptly during the phone call. The PA affirmed the finding during the interview.

B. Based on review of Hospital policy and staff interview, it was determined, that for the Complaint/Grievance policy, the Hospital failed to ensure the Complaint/ Grievance policy required a written response for the resolution of grievances.

Findings include:

1. Hospital policy titled: "Complaints/Grievances" was reviewed on 6/2/10 at 2:00 PM. The policy required: "Grievance... The grievance will be entered in the database... The Manager will investigate, address with staff, and return response within 14 days. The response will be conveyed to the complainant in writing or by phone..." The policy did not require notification of grievance findings must be in witting.

2. On 6/2/10 at 1:30 PM, the Chief Nursing Officer affirmed the finding during an interview.