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Based on record review and interview, the hospital failed to ensure written notice of a decision, in its resolution of a grievance, 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, was sent to the complainant. This deficient practice was evidenced by failure of the hospital to send written notice of a decision, in resolution of a grievance filed by Patient #2's family member, that included 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 for 1 (#2) of 1 patient reviewed for grievances from a total patient sample of 5.

Findings:

Review of the hospital's complaints/grievances from 08/2020 to present revealed there was a grievance regarding care and services Patient #2 had received during hospitalization. The grievance was dated 08/05/2020 and was submitted by Patient #2's family member. The grievance investigation was requested from S1QA. The grievance investigation documentation was provided by S1QA and reviewed by the surveyor.

In an interview on 06/23/2021 at 2:20 p.m. with S1QA, she confirmed she had not sent written notice of the hospital's decision, in its resolution of the grievance filed by Patient #2's family member, that included 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. S1QA reported there had been constant, ongoing communication with the complainant and she had not realized she had needed to send a written response in addition to the verbal communication with the complainant.