HospitalInspections.org

Based on policy review, document review, and staff interview, the facility failed to comply with the regulation 482.13 (a)(2), as evidenced by not dispersing written acknowledgement letters within the seven (7) day requirement of receiving the notification of a grievance in twenty-two (22) of the twenty-six (26) grievances reviewed.

Findings:

A review of the policy, titled "COMPLAINT AND GRIEVANCE MANAGEMENT & PATIENT SATISFACTION" last revised 07/22, states in part...United Hospital Center. Will provide a mechanism for receiving, responding to, and following up on complaints, grievances, suggestions and satisfaction rating of Patients, their families and other hospital guests. GRIEVANCES: A grievance is a formal, written or verbal grievance that is filed by a Patient when a patient, care or service issue cannot be resolved promptly by Staff present...Staff shall review, investigate, and resolve each patient's grievance as soon as practicable after it is received, taking into account the seriousness of the allegations and the potential for harm to the Patient...Grievances that do not involve situations that endanger the Patient shall be investigated and a decision regarding resolution made within seven (7) days of the receipt if the grievance.

A document review of "Complaints and Grievances" from September 1, 2024 to October 31, 2024, revealed:

Patient #1, filed a grievance on 09/03/24. The date of the acknowedgement letter was 10/24/24.

Patient #11, filed a grievance on 8/13/24. The date of the acknowledgement letter was 9/5/24.

Patient #12 filed a grievance on 8/13/24. The date of the acknowledgement letter was 9/3/24.

Patient #13 filed a grievance on 8/5/24. The date of the acknowledgement letter was 9/11/24.

Patient #14 filed a grievance on 8/22/24.The date of the acknowledgement letter was 9/11/24.

Patient #15 filed a grievance on 6/14/24. The date of the acknowledgement letter was 9/10/24.

Patient #16 filed a grievance on 8/14/24. The date of the acknowledgement letter was 9/16/24.

Patient #17 filed a grievance on 8/20/24. The date of the acknowledgement letter was 9/16/24.

Patient #18 filed a grievance on9/25/24. The date of the acknowledgement letter was 10/8/24.

Patient #19 filed a grievance on 8/23/24. The date of the acknowledgement letter was 10/9/24.

Patient #20 filed a grievance on 8/29/24. The date of the acknowledgement letter was 10/15/24.

Patient #21 filed a grievance on 9/5/24. The date of the acknowledgement letter was 10/15/24.

Patient #22 filed a grievance on 9/11/24. The date of the acknowledgement letter was 10/16/24.

Patient #23 filed a grievance on 9/26/24.The date of the acknowledgement letter was 10/16/24.

Patient #24 filed a grievance on 10/8/24. The date of the acknowledgement letter was 10/22/24.

Patient #26 filed a grievance on 10/16/24. There is no evidence of an acknowledgement letter being sent out.

Patient #27 filed a grievance on 8/29/24. The date of the acknowledgement letter was 9/11/24.

Patient #28 filed a grievance on 9/16/24. The date of the acknowledgement letter was 10/15/24.

Patient #29 filed a grievance on 9/5/24. The date of the acknowledgement letter was 10/22/24.

Patient #30 filed a grievance on 9/17/24. The date of the acknowledgement letter was 10/29/24.

Patient #31 filed a grievance on 10/8/24. The date of the acknowledgement letter was 10/29/24.

There were twenty-one (21) grievances that were not acknowledged within the seven (7) day requirement.

An interview was conducted on November 5, 2024 at 7:29 a.m. with Staff #7. Staff #7 stated, "I went over complaints and grievances with administration last night and they concurred that no seven (7) day letters were sent to any complainants."

An interview was conducted on November 5, 2024 at 1:30 p.m. with Staff #6. Staff #6 stated, "We send seven (7) day letters then thirty (30) day letters to follow up. It is the process to send the seven (7) day letters. I don't know why there isn't any."