HospitalInspections.org

A. Based on a review of Hospital policy and procedure, internal documentation, and staff interview, it was determined that the Hospital failed to ensure its grievance procedure followed the grievance process which effects all patients serviced by the hospital.

Findings include:

1. The Hospital policy and procedure titled, "GRIEVANCE MANAGEMENT FOR PATIENTS AND FAMILIES" was reviewed. It stated under "II. GRIEVANCE PROCESS Types of Grievances: 1. Unresolved Patient or Family Complaints B. Within approximately 7 days of receiving a grievance, the manger of Customer Service...will provide a formal written notice to the complainant indicating an investigation and review of the facts is being undertaken. Following the investigation, a written explanation describing the steps taken on behalf of the complainant, the results of the investigation, along with the name and phone number of the manager of Customer Service or designee will be provided to the complainant within 30 days..."

2. Internal documentation indicted that only phone contacts and updates were provided to the complainant. There was no documentation that indicted written notification was provided at the 7 day and 30 day benchmarks as required in the policy and procedure.

3. During an interview with the Rehabilitation Manager, conducted on 5/11/11 at 2:15 PM, it was verbalized that all contacts with the complainant were made by phone and that no written notices were sent to the complainant.