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UNIVERSITY MEDICAL CENTER OF EL PASO
PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION
Tag No.: A0123
Based on a review of documentation and interview the facility failed to ensure in its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Findings included:
Facility policy entitled, "PATIENT COMPLAINTS" stated in part,
"12. Guest Services will provide a written response to the Guest or designee with results of the review for only those Guest Grievances related to the of quality medical care and treatment. The written response will include, but is not limited to the notice containing the name of the EPCHD contact person, efforts made to investigate the concern, the results of the process, and the date of completion."
Review of grievances for August and September 2021 revealed 3 patients (#1,3, and 4) with grievances lodged with the facility. 2 of the grievances (involving patients #3 and 4) had written responses in the form of a letter from the facility sent to the complainant. One grievance involving patient #1 had no written response or letter per policy. Documentation indicated that no letter was sent to the complainant regarding the care of Patient #1 due to the complainant not being "next of kin".
In interview on 12/01/21 staff member #6 verified ""A letter was not sent to the daughter beacuse she was not next of kin".
Per Centers for Medicare Interpretative Guidance, "The written notice of the hospital's determination regarding the grievance must be communicated to the patient or the patient's representative in a language and manner the patient or the patient's legal representative understands. "
Per regulations and facility policy any patient representative filing or making a grievance should receive written notice of the hospital's determination regarding the grievance.
In an interview on 12/01/21 staff members #2 and 6 verified the above findings.