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MEMORIAL HERMANN HOSPITAL SYSTEM 1635 NORTH LOOP WEST HOUSTON, TX 77008 Oct. 3, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on interview and record review the facility failed to ensure compliance to its grievance policy for 2 out 3 sampled patients with documented grievances (patients # 1, #4)

One patient (ID #1) did not receive a written response post-investigation, and one patient (ID #4) received a late post-investigation letter.

Findings include:

Record review on 10/3/2017 of the facility Customer Experience Tracking log for grievances from May, June and July 2017 revealed a listing of complaints by date, issue and status. Three complaints were selected for review of facility investigation and follow up.

Patient (ID#1) received a formal written acknowledgement within seven (7) working days dated 6/13/2017 stating the leadership team would respond directly to the patient. The patient did not receive a post-investigation letter. Patient fell on the hospital grounds.

Patient (ID#4) received a closure letter dated 7/7/2017, 56 days later the formal written acknowledgement letter was sent dated 5/11/2017. Patient fell in the hospital.

Interview on 10/3/2017 at 11:10 a.m. with the Director of Patient Relations (staff #A) she stated if it is not documented it was not done.

Record review of the current facility policy titled Patient Relations: Complaints/Grievances, Hospitals Response Procedures dated 8/31/2016
"Patient Relations will coordinate final written notices of resolution within thirty (30) calendar days.".