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TRINITY HEALTH GRAND RAPIDS HOSPITAL
PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES
Tag No.: A0122
Based on document review and interview, the facility failed to follow their grievance process for one of four patients (#6) grievances reviewed. Resulting in the potential to have unresolved grievances/unmet patient rights. findings include:
On 11/29/2016 at 1500 the grievance log was reviewed. Four patients grievances (#6, #7, #8, and #9) were chosen based on similarities in the nature of the complaint related to staff care and discharge process.
On 11/29/2016 at 1630 the grievance file for patient #6 was reviewed. The grievance was dated 10/18/2016. It was dated resolved on 10/21/2016. There were no letterers included in the file. The outcome notes documented that the case was handed over to the area claims manager.
On 11/30/2016 at 0840 the computerized files for patients #7, #8 and #9 were reviewed. Each of the computerized files included detailed information beginning with the nature of the grievance, it included dates for the acknowledgement of the grievance, resolution, and letter of resolution. The files for patient #7 and #8 contained copies of the letters that were sent acknowledging the receipt of the grievance and the finale letter that included the investigative steps that were completed. Patient #9 had included the statement "I do not want to be contacted for follow up" in her original complaint documentation.
On 11/30/2016 at 1247 staff FF and GG from risk management were interviewed. Staff FF stated "We did not send any letters (to patient #6) because the patients son was planning to sue, so we turned it over to area claims." Staff FF was also asked if this change in the process was documented in a policy or procedure, he replied "I don't think so."
On 11/30/2016 at 0935 the policy titled "Patient Complaint-Grievance Process" #INST.10-107 dated effective 07/2016. It states on page 2-3 under "Process:...The patient or patient advocate will be contacted in writing within the initial seven (7) days and informed they will be updated by a certain date or, at the latest, within thirty (#30) days with additional information concerning the status of the review. Written correspondence with the patient or patient advocate will occur every 30 days thereafter, until the issue has been resolved."