HospitalInspections.org

Based on review of hospital policy, hospital records and staff interview, the hospital failed to ensure that 2 of 2 patient grievances (Patient #'s 1 and 2) received by the hospital, had written response notices provided to the patient/ patient representative that contained the name of the hospital contact person, the steps taken to investigate the grievance, the results of the investigation and the completion date. This has the potential to affect all patients/ patient representatives filing a grievance with the hospital.

Findings include:

The 7/10/13 review of "Complaint and Grievance Policy, reviewed 4/7/2010" documents "...10. In the resolution of the grievance , the written response must include the name of the contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the investigation and the date of completion. The written response should be shared with the Risk Manager to review for possible potential liability issues."

1) The 7/10/13 review of facility records records received from Risk Manager B at approximately 11:30 a.m. reflects that a written grievance letter dated on 3/8/13 was received from Patient #2's representative. This grievance letter detailed a complaint about Patient #2's discharge planning information, dates of in-patient stay and the financial burden of a SNF (skilled nursing facility) stay, after Patient #2 did not quality for a Medicare 3-day hospital stay. Continued review of this information documents that a written response was provided by the hospital's legal counsel on 3/26/13 to Patient #2's representative. Review of this written response by the hospital's legal counsel does not include the investigative steps taken to resolve the concerns nor the date of completion for the investigation.

In interview with Risk Manager B on 7/10/13 at approximately 11:30 a.m. she stated that she did not think that she had to respond to the complainant if the situation had become a legal matter for the hospital, and the hospital's legal counsel would take over. Risk Manager B stated that the required federal components of investigative steps taken and date of completion were missing in the legal counsel's 3/26/13 written response letter, and stated that she had no written correspondence with Patient #2's representative. Risk Manager B stated that she could not produce any documents that would reflect that these written response notice requirements were met.

2) The 7/10/13 review of facility records received from Risk Manager B at approximately 11:30 a.m. reflects that on 12/27/12 a " Patient Relations Worksheet" records a complaint from Patient #1's spouse about care received in the emergency department. It records that Risk Manager B documents conversation with spouse about "request for peer review", and "compensation" from the ED physician who cared for Patient #1 on 12/25/12. These documents show that a physician peer review was conducted on 2/16/13, to review care received by Patient #1 during the 12/25/13 ED (emergency department) stay, and a discussion was held about this complaint on 3/5/13 at the ED committee meeting. There is no documented evidence of a written response
to the spouse (complainant).

In interview with Risk Manager B on 7/10/13 at approximately 11:30 a.m. she stated that she had not written a grievance response letter to Patient #1's spouse that contained the name of the hospital contact person, the steps taken to investigate the grievance, the results of the investigation and the completion date. Risk Manager B stated that she could not produce any documents that would reflect that these written response notice requirements were met.