HospitalInspections.org

Based on review of the hospital policy and procedure and interview with the Associate VP Quality and Patient Safety 8/15/13, it was determined that the hospital does not meet the expected length of time for resolution of grievances nor timely provision of a written response.

A review of the hospital's policy "Patient Complaints and Grievances" last revised October 2011 does not address and timely completion of grievances. Per the policy, when a grievance is received, it is forwarded to the Patient Relations Department for follow up, which begins with: a written acknowledgement of the grievance within 7 to 10 days; and convening an ad hoc sub-committee of Quality & Performance Improvement Council members plus others who have responsibility for the relevant areas to review and resolve the grievance. The Patient Relations Department coordinates the investigation and, within 30 days, provides a written notice to the complainant with all the elements.

The hospital has not met the regulatory requirement to provide a written response to a grievance on average within 7 days. In addition, the policy does not address if a grievance cannot be resolved or the investigation is not completed within the 7 days, the hospital process for informing the complainant of the hospital's efforts to resolve the grievance and follow-up with written response within a stated number of days.

Based on review of the hospital policy on restraint, the hospital's policy failed to address the timely acquisition of the order for restraint prior to its application or in emergency application situations.
Per the hospital policy which is being revised, under non-violent/non-self-destructive the LIP (Licensed Independent Practitioner) is notified immediately after the initiation of the restraint and verbal or written order is obtained. The policy does addresses that the order will be obtained immediately but does not clarify that immediately means within a few minutes. Under the "Use of restraint: For the Violent or Self destructive behavior" the policy does not state the order must be obtained immediately (within a few minutes). The hospital policy has not met the regulatory requirements since it does not address the process for timely acquisition of restraint in its restraint policy and procedure.