HospitalInspections.org

Based on review of the hospital's policies/procedures, staff interview, and review of the hospital's internal documents the facility failed to ensure that in its resolution of patient grievances that the hospital provided a written notice of its decision that contained 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.

The findings were:

A review of the hospital's policy titled "Patient Complaint/Grievance" last revised August 2011, revealed the following, in pertinent part:
"...Step 3: Investigation
a.) The Risk Manager will investigate the grievance and respond to the patient, on average, within seven (7) working days, but up to fifteen (15) working days of the submittal of the grievance...
b.) After investigation, which may include a meeting with the patient and his/her family, and appropriate input from management and others, the Risk Manager will provide the patient with a written report o(r) personal phone call regarding the hospital's decision regarding the grievance, which includes:
i.) The name of the Risk Manager or other hospital contact person;
ii.) The steps taken by the hospital on behalf of the patient to investigate the grievance.
iii.) The results of the grievance process
iv.) The date of completion..."

A review of a sample of the hospital's grievances that had been resolved were reviewed with the risk manager on 10/18/2011 at approximately 2:30 p.m. The review included three complaints/grievances. Upon discussion with the hospital's Risk Manager regarding follow-up on the grievances, s/he stated that out of the three complaints, only one was sent a letter. S/he stated that "we don't send formal letters, we usually meet them [patients or the patient's representatives with grievances] in person." When asked if the facility could provide the letter for review, s/he stated that the facility was unable to do so, because a copy had not been retained.