HospitalInspections.org

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion were provided to the complainants. One (#1) of three grievances reviewed did not contain a written response to the complainant containing the required elements. Two ( #'s 2 & 3 ) of three grievances did not have any written response.

Findings:

1. These three grievances were marked resolved on the grievance log, but two did not have a written response to the complainant and the one with a written response did not contain the required elements. The hospital classified grievances as either formal or informal.

2. Hospital Staff C stated on 03/02/10 in the afternoon that the hospital believed grievances/complaints that were classified as formal needed a written response and the informal did not. Staff C also verified these three complaints required an investigation and were not resolved at the time of the complaint by staff present.

Based on the review of abuse and neglect policies and procedures and various policies from the human relations department and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review. The policies concerned child abuse, elder abuse, sexual abuse and spousal/domestic abuse concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with hospital staff on 03/02/10 in the afternoon verified that the hospital does not have a written policy that includes the required elements for effective abuse protection.