HospitalInspections.org

Based on record review and interviews, the hospital in its resolution of patient grievances failed to provide 7 of 7 patients (Patient #2, #3, #4, #9, #11, #12, #13) with an effective grievance resolution process in that the patients did not receive written notice of its decisions, steps taken on behalf of the patients, the results of the grievance process, and the date of completion.

Findings included:


Patient #2 completed a written Customer Care/Concern Form on 08/20/13 at 18:00 that his rights were violated. A handwritten note completed by Patient #2 and dated 08/21/13 at 09:19 noted that it was the "second written complaint" of patient rights' violation. Neither document showed evidence of a follow up action by hospital staff.


Patient #3 completed the Patient /Family Grievance document on 08/23/13 at 06:35. The spaces for Patient Advocate's investigation and resolution were left blank. Patient #3 did not receive a copy of the grievance resolution.


Patient #4 was involuntarily hospitalized on 08/02/13 and discharged on 08/05/13. The patient complaint dated "8/20" did not provide any evidence of steps taken by the Patient Advocate, result, disposition, or resolution of the patient grievance.


Patient #9 was hospitalized on 08/25/13 and discharged on 08/26/13. There is no evidence of a complaint resolution to Patient #9's written complaint dated 08/26/13.


Patient #11's mother wrote a written complaint on 12/09/13. The document did not provide any evidence of Patient Advocacy follow up actions. The patient's responsible party did not receive a copy of the grievance.


On 11/21/13, Patient #12's parents provided a written complaint. There is no evidence the Patient Advocate took action to investigate or resolve the complaint. The guardian did not receive a copy of the grievance resolution.


On 11/05/13, Patient #13 provided staff with a written complaint. There is no evidence that the complaint was followed up. Patient #13 did not receive a copy of the resolved grievance.



Hospital Personnel #2 was interviewed on 12/23/13 at 14:00 and stated it was the hospital's Patient Advocate's responsibility to follow up and investigate patient complaints.



Hospital Personnel #3 was interviewed on 12/30/13 at 11:00 and denied having investigated the patients' complaints. Hospital Employee #3 stated the grievance process "needs improvement."


The Patient and Family Grievances/The Role of the Patient Advocate Policy dated 10/01/05 noted the Patient Advocate's responsibility to respond to patient grievances "promptly," investigate within 24 hours, and provide feedback to the patient.