HospitalInspections.org

Based on staff interview, review of eleven reported complaints/grievances and review of the hospital Complaint/Grievance Policy & Procedure it was determined that hospital failed to provide patients with a written response of the hospital's decision regarding the individual complaints/grievances. (Patient identifier's are #1 thru #11)

Review of the hospital policy and procedure titled "Complaint/Grievance Policy & Procedure" on 7/22/14 with a revision date of "04/14/2010" revealed in the section titled "Addressing Complaints and Grievances" the following:

"... Once all information has been gathered, a collaborative effort is made between the patient and staff to clarify and swiftly resolve the patient's concerns. Oral or written correspondence is sent to both the patient and ... (hospital) staff regarding COMPLAINT resolution. Within seven days of filing of a GRIEVANCE, the appropriate person handling the grievance is responsible for providing written notification to the patient or their representative of the outcome of the investigation, including the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance review process and date of completion. If resolution cannot be completed within seven days, an acknowledgement letter is sent to the patient or their representative. This letter should state that a resolution or follow-up letter will be sent as soon as possible, but within 30 days. If the grievance is not resolved within 30 days, there will be frequent updates to the patient or representative as to the status of the investigation...".

Complaint #25044 for Patient #1 was investigated at this time. During interview with Staff A (Clinical Quality Specialist) and Staff B (Risk Management) on 7/23/14 along with the medical record review for Patient #1 revealed that the hospital had a "formal complaint" submitted regarding Patient #1 dated "May 30, 2014." Staff A and Staff B reviewed the hospital Complaint/Grievance policy and procedure listed above and verbalized that this policy and procedure was not followed for Patient #1 in that no documented evidence could be found to show that a written notice had been provided to Patient #1 for submitted Complaint #25044.

Review of 11 patient complaints/grievances on 7/22/14 with Staff A, Staff C (Director of Care Management & Patient Relations Case Manager) and Staff D (Patient Relations Specialist) and interview with these staff at the same time revealed that the 11 patients reviewed had not been provided with a written notification of the outcome of the investigation including the name of the hospital contact, steps taken to investigate the complaint/grievance, the results of the review process and date of completion.

The hospital could provide no documented evidence of any written notification to these 11 patients of the outcomes for each individual complaint/grievances following the hospital investigation to include the steps taken to investigate the individual complaint/grievance, the results of the completed review process, the name of a hospital contact and the date of completion.