HospitalInspections.org

Based on record review of 2 sampled patients (Patient #10 and #11) in a total sample of 10, interviews, two grievance notices (letters) and the Hospital policy titled, Complaint & Grievance, the Hospital failed to follow its own grievance policy.

Findings include:

1.) The Hospital policy titled: Complaint & Grievance, dated 2/13, indicated that a written response regarding the complaint or grievance will be provided to the patient or representative and the letter will include:
a.) the name of the hospital contact person,
b.) the steps taken to investigate the complaint or grievance,
c.) results of the complaint or grievance process and
d.) the date of completion.

2.) The notice of grievance (letter) written by the Associate Chief Emergency Department (a physician) to Patient #10 did not indicate the name of the Hospital contact person, the result of the complaint or the date of completion.

3.) The notice of grievance written to Patient #11 by the Hospital Risk Manager did not indicate the name of the Hospital contact person or the date of completion.

4.) The Surveyor interviewed the Hospital Risk Manager on 2/24/14 at 8:30 A.M. The Risk Manager said that sometimes the Associate Chief of the Emergency Department (ED) wrote and mailed letters to patients regarding their complaint or grievance. The Risk Manager said that she did not review the letter written by the Associate Chief of the ED to Patient #10. The Risk Manager said that she intentionally does not include, in the patient letter, the date of completion because patients were always welcome to call the Hospital regarding their complaint and she always talks to the patient prior to mailing the letter. The Risk Manager said that the telephone number on the Hospital stationary letterhead served as the Hospital contact number.

The Risk Manager and the Associate Chief of the Emergency Department failed to comply with the Hospital's Complaint and Grievance policy.

The Hospital telephone number, included on the Hospital stationary letterhead, was not the telephone number of the Hospital contact person. The Surveyor called the telephone number included on the Hospital stationary letterhead and the number was the Hospital's main telephone number. The telephone number connected the Surveyor to the Hospital's operator. The Hospital operator would then need to connect a patient to the Hospital contact person and the letter did not indicate the contact person. This was not a clear process for many patients.