HospitalInspections.org

Based on interview and record review it was determined the hospital failed to implement hospital procedures in the resolution of a grievance related to the care of 1 of 5 sampled patients (Patient 5). Findings include:

Patient 5 had been admitted to the hospital on 5/8/10 with a complex medical condition that included chronic blood loss, severe malnutrition and presumed esophageal cancer with obstruction. At the time of admission, Patient 5 was accompanied by a friend, Witness D. No other family member or representative was present or available between 5/8 and 5/10/10.

During that stay a complaint was registered with hospital staff regarding various aspects of Patient 5's medical care. Interview and record review revealed that Witness D registered a complaint with hospital management and patient advocacy staff on both May 11 and May 17, 2010.

Policy review revealed that the hospital had a specific policy, "Patient Complaint/Grievance Procedure" that outlined the procedure to be followed in the resolution of a complaint. That policy indicates that "the patient or representative will be notified within 7 days of receipt of the grievance and the timeframe needed to complete the grievance."

The procedure also indicates that the written notice of the grievance will include specific information such as the name of a contact person, the steps taken in the investigation, the result of the investigation and the date of completion. The policy provided no specific identification, categorization or exclusion from the procedure for a complaint registered by a "friend."

During an interview with Witnesses B and C on 6/21/10, and record review determined that hospital procedures had not been implemented in the resolution of Witness D's complaint regarding Patient 5. Witness D was not notified of a receipt of a grievance, or provided written notice of the specific information as directed in policy.

The hospital failed to provide written notice of its decision to Witness D as required.