HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure patient's grievances were reviewed, investigated and resolved within a reasonable time frame.

Findings included:

Facility policy titled "Patient Grievance Process" stated in part, "Policy
1. Patients have the right to express concerns and expect resolution in a timely manner.
2. The Governing Body has delegated the Complaint and Grievance process to the Hospital Quality Council. A sub-committee of the Quality Council may be formed to monitor effectiveness of the grievance process and to review and resolve grievances in an appropriate manner and time frame ...
6. If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that a follow-up written response will be provided within a specified time period but not to exceed 30 days until the grievance is resolved. If the grievance remains unresolved after 30 days, additional written follow-up would be indicated within a specified time period but not to exceed an additional 30 days. "

Review of facility letters sent to patient #1 revealed two letters, one dated January 5, 2017 stated in part, "Our Quality Department is conducting a review of the care that you received. Based on the results of the review, we will determine further recommendations and action. We will follow-up with a written response to you within 30 days."
The second dated February 3, 2017 stated in part, " ...our hospital is continuing its review of the care that you received. We apologize that the review is taking longer than anticipated.
Based on the results of the review, we will determine further recommendations and action. We will follow up with a written response to you within 30 days."

In an interview with staff #2, the risk manager, she stated, "We sent two letters, but failed to follow-up."

The above was confirmed in an interview with the Chief Quality Officer on the afternoon of 5/17/17.