HospitalInspections.org

Based on hospital policy review, grievance file review and staff interview, the facility failed to provide a written response to a grievance for 2 of 3 grievance files reviewed (Patient #4 and #25).

The findings include:

Review of the hospital's "Patient Complaint/Grievance Resolution Process Policy and Procedure" approved 03/30/2015 revealed "... Patient Grievance is a written or verbal complaint (when the verbal complaints about patient care and is not resolved at the time of the complaint by staff present or who can quickly be at the patient's location) by a patient, or the patient's representative, regarding (1) the patien's care, (2) abuse or neglect, (3) issues related to facility's compliance with the CMS Hospital Conditions of Participation (COP) ...5. Upon receipt of the patient complaint/grievance through the online reporting system, the patient Relations Manager (PRM) will assign the complaint/grievance to the appropriate administrator, director, manager, supervisor, or designee for investigation and resolution within the required time frames. ...6. Within seven (7) calendar days, the patient/representative will be sent a letter drafted by the PRM and signed by the appropriate (hospital name) leader which addresses a resolution or notifies the patient that further investigation is required. ... All complaints/grievances will be resolved as soon as possible with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 calendar days. ..."

1. Review on 12/07/2016 of a grievance filed on 11/22/2016 at 1730 revealed Patient #4's family member submitted a grievance regarding lack of patient care and safety resulting in a patient fall with injury. Review of the file revealed an investigation was conducted and staff retraining was done. Review of the grievance file revealed no written response to the grievance was done. Review revealed the grievance was closed on 12/05/2016.

Interview on 12/08/2016 at 1020 with PRM #1 (Patient Relations Manager) revealed the grievance was investigated and the nursing unit manager talked with the family member via telephone. PRM #1 stated the issues were resolved and the grievance was closed on 12/05/2016. The staff member revealed no written response was sent. The staff member confirmed she failed to follow the hospital policy.

2. Review on 12/07/2016 of a grievance filed on 11/14/2016 at 0700 revealed Patient #25's family member submitted a grievance regarding lack of patient care. Review of the file revealed an investigation was conducted and staff retraining was done. Review revealed the nursing manager talked with the family member on 11/16/2016 regarding the investigation findings. Review of the grievance file revealed no written response to the grievance was done. Review revealed the grievance was closed on 11/17/2016.

Interview on 12/08/2016 at 1020 with PRM #1 (Patient Relations Manager) revealed the grievance was investigated and the nursing unit manager talked with the family member. PRM #1 stated the issues were resolved and the grievance was closed on 11/17/2016. The staff member revealed no written response was sent. The staff member confirmed she failed to follow the hospital policy.