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327 MEDICAL PARK DRIVE

BRIDGEPORT, WV 26330

PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES

Tag No.: A0122

Based on document review and staff interview it was determined the hospital failed to follow their policy for Complaint and Grievance Management and Patient Satisfaction. This deficient practice was identified in one (1) of one (1) records reviewed (patient #1). This failure has the potential to adversely affect the rights of all patients.

Findings include:

1. Review of the hospital policy titled "Complaint and Grievance Management and Patient Satisfaction", last revised 1/16, revealed it states, in part: "Grievances that do not involve situations that endanger the patient shall be investigated and a decision regarding resolution made within seven (7) days of the receipt of the grievance if reasonably possible."

2. A review of the complaint/grievances log from July 2016 through August 2017 and incident log from 6/1/16 to 7/31/16 revealed a grievance was filed for patient #1 on 3/13/17.

3. A review of the hospital's Patient Complaint Form revealed the family of patient #1 filed a grievance on 3/13/17 and an investigation was completed by the hospital from 3/13/17 through 3/14/17. A letter of resolution was sent to the family on 3/23/17. The hospital failed to follow their policy.

4. An interview was conducted on 8/23/17 at 10:55 a.m. with The Patient Safety/Joint Commission Registered Nurse. She confirmed no other correspondences, except one (1) dated 3/23/17, was sent to the family concerning the grievance filed on 3/13/17.