HospitalInspections.org

Based on staff interview, review of facility documents, and policy/ procedure, the facility failed to ensure a process was in place for prompt resolution of patient grievances and failed to follow their grievance policy's timeframe.

The findings:

1. GRIEVANCES

a. Review of facility grievances was conducted on 3/24/12. Grievance #1 revealed a patient's allegation of mis-diagnosis wherein s/he stated s/he went to another medical facility two days after discharge and was told s/he had a kidney infection. The grievance was submitted on 3/30/11 and the final resolution letter was sent on 5/23/11, approximately 37 business days later.

b. Grievance #2 revealed a patient's representative who alleged nursing staff nearly administered the wrong dosage of medication to the patient, staff was confused about the identity of patients, and the patient was not on any monitoring after a head injury. The grievance was submitted on 8/25/11 and the final resolution letter was sent on 10/3/11, approximately 26 business days later.

c. Grievance #3 revealed a patient who alleged s/he did not get treatment for hypoglycemia for almost an hour and s/he heard another patient's privacy rights violated. The grievance was submitted on 10/4/11 and the final resolution letter was sent on 11/16/11, approximately 22 business days later.

d. Grievance #5 revealed a patient who not happy with the diagnosis, treatment, and resulting consequences. The patient had surgical procedures at the facility, alleged s/he later got an infection, and needed additional surgical procedures/ care. The facility could not determine when the initial grievance was submitted, as their current computer tracking system was not in use then. The patient persisted with her/his grievance and it was submitted into the current system on 8/24/10 by staff in the billing/ accounting department. The final resolution letter was sent on 11/23/10, approximately 63 days later. It is unknown how long after the patient's initial grievance submission that the final letter was sent as facility staff had no knowledge or documentation of the original grievance.

2. STAFF INTERVIEWS

a. An interview with the Vice President of Quality and Risk was conducted on 5/22/12 at approximately 10:30 a.m. Two grievance policies were provided for review. When asked which was in use and most accurate to the facility's processes, s/he stated, "We are getting the draft version approved next week."

b. An interview with the Director of Patient Relations/ Patient Advocate was conducted on 5/24/12 at approximately 12:00 p.m. The Director was asked about each grievance wherein a resolution letter was not sent in 15 working days per their policy. S/he stated much of the issue with resolutions were when the responses were "tasked-out for mid-level review (sent to managers)." S/he stated the response committee had discussions and elevated the grievances to Administration and responses had improved since then. However, s/he stated that PARC meets weekly to review grievances and, if information is completed Friday, for example, but the agenda has already gone out for the Monday meeting, the grievance gets kicked back to the following week. S/he confirmed that grievances #1, 2, 3, and 5 were not resolved in the 15 day timeframe. When asked if s/he communicated with the complainant who submitted grievance #5 anytime prior to the resolution (between 8/24/10 and 11/30/10), s/he confirmed it wasn't documented, s/he did not recall, and s/he did not know why such a long delay had occurred.

3. POLICY/ PROCEDURE

The facility's draft policy, titled "Patient Grievance Policy and Procedure," stated, in part: "The patient will be informed in writing of PARC's resolution within 15 business days. If PARC cannot come to a resolution in this designated timeframe the patient will be notified of such delay in writing."