HospitalInspections.org

Based on document review and interview, the facility failed to provide a written response to a patients grievance for one (1) of ten (10) medical records (MR's) reviewed. (Patient # 10)

Findings include:

1. Review of the hospital policy titled, "Patient Complaint/Grievance Mechanism Policy", policy Stat ID number 5920738, indicated in "all cases" the hospital must provide a written response which would include, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance, the decision and the date it was completed. This policy was last revised on 01/25/2019.

2. Review of facility complaints/grievances indicated there was a complaint/grievance filed on 12/8/20 by the family of patient # 10 indicating that the patient was sexually assaulted while a patient at the facility.

3. Review of the Grievance Committee Meeting Minutes, dated January 2021, indicated the patient # 10 had not received a closing letter with the results of their grievance/complaint.

4. In interview on 04/13/2021 at approximately 11:30 am with administrative staff member A # 9 (Risk Management Manager), confirmed that he/she "should have sent a letter" with the results of the grievance investigation.

5. In interview on 04/13/2021 at approximately 3:40 pm with administrative staff members A # 1 (Director of Nursing-DON) and A # 2 (DON)\, confirmed the Risk Management Department doesn't have supporting documentation related to the follow up letter post investigation.