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.

Based on interview and review policy and of grievance files, it was determined that the hospital failed to establish a process for prompt resolution of patient grievances. The hospital's failure to do so resulted in lost, incomplete and unresolved grievances for an unknown number of grievants.

Findings include:

Review of the hospital's policy and procedure "Patient Grievance/Complaint Management" revealed that the purpose of the process was to "...provide a mechanism by which a patient or patient's representative will be able to voice complaints...". Reference to "patient or patient representative" was found throughout the policy. Discussion was held with hospital leadership, who acknowledged that the wording appeared to imply that only patients or their representatives could file complaints or bring forth concerns.

Review of the grievance log for June and July, 2010 did not reveal any complaints or grievances received by the hospital in reference to Patient #1, the patient identified in the complaint. At approximately PM on 8/25/2011, the Chief Executive Officer, the Chief Nursing Officer, the Director of Quality and the Risk Manager stated to investigators that a file containing a complaint/grievance and a request for contact regarding the care of Patient #1 had been located. The date on the email from the complainant was July 9, 2010.

The Director of Quality stated that the file had been "lost" and s/he did not know if the complainant had ever been contacted. The Director stated that there had been some staff turnover in the department, and staff was behind in filing and in referrals to Medical Staff Peer Review, but was working to get up to date. The Director also acknowledged that s/he did not know the status of grievances in the department and how many other cases might also have been lost.

Four (4) grievance files were reviewed to ascertain timely and accurate resolution of grievances.

Grievance file #1:
The file revealed that the hospital had received a telephone call from the complainant on 8/25/2010, with a complaint about care in the hospital's Emergency Department. A letter from the hospital was sent to the complainant on 10/27/2010 which stated that the review had been completed on 10/22/2010.
The grievances was not completed within 7 days, per the hospital's policy, nor did the letter contain the steps taken to investigate or resolve the issue, or who to contact with questions.

Grievance file #2:
The grievance file contained documentation that the hospital received a call from the complainant on 8/19/2010, who complained about billed charges. The response letter to the complainant was dated 8/18/2011, one year after the complaint was received. The letter was incomplete and did not describe the steps taken to investigate or resolve the issue, or who to contact with questions.

Grievance file #3:
Review of the grievance file revealed a letter from a complainant dated 8/17/2010. The letter stated that on 8/9/2010 the complainant had spoken with [the patient representative]. The 2-page letter stated that s/he was only willing to give additional details to someone who could fix the problem.
A letter from the hospital dated 8/19/2010 stated that the complainant's concerns were forwarded to the Medical-Surgical Director and [a specific person] "will be making follow up with you".
The letter also stated that [the patient representative] "will follow-up with you regarding the missing wallet" and [another named person] "will follow up with you regarding the attending MD".
The file did not contain any documentation that any of the 3 named persons had followed up with the complainant or that the case had been resolved. The Director of Quality was unable to answer when asked if the case was finished or not.

Grievance file #4:
Review of the file revealed that a complainant had called on 6/3/2010 and was concerned about a long wait in the Emergency Department. The letter to the complainant, dated 6/4/2010, did not state what steps had been taken to investigate and resolve the complaint, the date of the completion of the investigation or who to contact with questions.