HospitalInspections.org

Based on policy and procedure review, grievance file review, and physician and staff interviews, the facility staff failed to provide a written letter of resolution that contained ALL of the following required elements: 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 for 1 of 1 grievance files reviewed. (Grievance File #1)
The findings include:

Review of current hospital policy "PR (Patient Rights) Patient Grievance Management", revised 04/16/2015, revealed "...POLICY: This policy sets forth the procedure for appropriately identifying and promptly resolving patient grievances....PROCEDURE OR PROCESS....D....Written responses will include 1. Name of the hospital contact person 2. The steps taken on behalf of the institution to investigate the complaint 3. The results of the grievance process 4. The date of completion. ..."

Review on 03/01/2016 of a hospital grievance file (File #1) for Pt # 3 revealed a complaint submitted by Pt #3's sister on 12/14/2015. File review revealed a response letter to Pt #3, dated 01/29/2016 which stated "...Your concern regarding the Emergency Department physician and physician assistant's behavior have been addressed by the Medical Director for the Emergency Department, the Chief Nursing Officer and the Emergency Department Clinical Coordinator. We apologize for any inconvenience you may have experienced. Although we are unable to disclose details of the review, please be assured we take this matter seriously and have investigated thoroughly. ..." Letter review did not reveal the steps taken to follow up on treatment concerns and did not reveal the results of the investigation.

Concurrent interviews on 03/02/2016 at 1215 with Staff # 1 and Director (Dir) # 1 revealed their department receives and handles grievances. Interview revealed response letters to patients generally include the steps taken to follow up on the complaint and the results of the investigation. Interview revealed a decision was made not to include specific details in this letter. Further interview revealed Dir #1 could see the issues with this situation and the facility had opportunities to improve.

NC00113295