The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HENRY FORD HOSPITAL 2799 W GRAND BLVD DETROIT, MI 48202 Nov. 17, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record the facility failed to follow its policy and procedure related to prompt response for grievances for 1 (#18) of 2 patients reviewed for grievances, out of a total of 20 sampled patients, resulting in the potential for unresolved and prolonged patient grievances. Findings include:

On 11/17/16 at 1030 a review of the closed electronic medical record documented the patient #18 was an [AGE] year old female admitted to the facility on [DATE].

On 11/17/16 at 1040 a review of the grievance file and investigation for patient #18 was conducted with Chief Nursing Officer Staff B. Staff B explained the grievance was received via e-mail on 9/8/16, but was not forwarded to the appropriate department for further review and investigation until 9/27/16.

On 11/17/16 at 1115 further review of the grievance file and investigation for patient #18 revealed an e-mail dated 9/8/16 from patient #18's representative that explained multiple issues with care, treatment and services during the patient's length of stay. (9/6/16 through 9/9/16).

A response to the grievance by the facility dated 9/27/16 via e-mail at 0834 offered an apology for the untimely (19 days) delay in addressing the concerns of the grievance.

On 11/17/16 at 1130 a review of the facility's undated, "Patient Experience Guide Admission" folder revealed a documented titled "Questions or Concerns? You and your family should feel you can always voice your concerns. If you share a concern or complaint, your care will not be affected in anyway. We are committed to resolving your concerns while you are here....E-mails may be sent to (name of organization)".

A review of the facility's "(Name of organization) Feedback Reporting (Compliment, Complaint, Grievance) Policy No: I.C.3 (dated 3/2/14), documented:
1.3.3 A written complaint (e.g. e-mail, fax or letter) received from a patient or patient representative constitutes a grievance.
2.3.2.1 Grievances will immediately be brought to the attention of the involved manager(s)
and Patient Relations/Service Excellence staff by phone and/or e-mail in order to meet the CMS 7-day timeline for response back to the patient."

On 11/17/16 at approximately 1220 Staff B stated, "We will have to review our processes for reporting grievances to make sure this does not happen again."