HospitalInspections.org

Based on policy review, grievance file review, and staff interview, the hospital failed to provide a patient with a written acknowledgement of and investigate a patient's grievance per facility policy for 1 of 2 sampled grievance files (Patient #6).

The findings include:

Review of current hospital policy entitled "Management of Grievances" dated 07/2010 revealed, "...PROCEDURES:...4. Upon receipt of the patient grievance, the concerns will be entered into the Feedback Management System (electronic tracking system). The Service Excellence Department will provide a written acknowledgement of the grievance to the patient or the patient's representative. The director or their designee will investigate the grievance and will notify administration or Risk Management as appropriate....5. Within seven calendar days, the patient or the patient's representative will be provided written follow-up addressing a resolution or notifying the patient that further investigation is required...."

Grievance file review on 03/07/2012 for Patient #6 revealed on 02/08/2012 the patient filed a grievance at Hospital B (another hospital within the same healthcare system) regarding problems with the process of having an outpatient test scheduled. File review revealed the grievance was forwarded to the Patient Registration office for review. Review of documentation by Patient Service Advocate #1 on 02/13/2012 at 1320 revealed, "Added note: (Patient #6) was seen in the ED (emergency department) at (Hospital A - named hospital) on Feb. 10th. (Name of staff member) called her as a discharge phone call on Feb. 13th. (Patient #6) was very unhappy about her care. She stated the doctor was rude to her and told her to 'never come back here anymore, we will not see you here again.' (Patient #6) stated that she knows that 'this is against the law..we have to see her and that she is going to see an attorney and sue the hospital.' It was noted that she also threw urine on a nurse while she was being treated here." Further file review revealed no documentation the patient was provided a written acknowledgement of the grievance regarding her care in the ED (23 days after grievance received). File review revealed no documentation the hospital had investigated the patient's grievance regarding her care in the ED. Further file review revealed on 02/17/2012 at 1413 the grievance file was closed.

Interview on 03/08/2012 at 0900 with Patient Service Advocate #1 revealed when the advocate received a patient grievance she entered it into the Feedback Management System and sent the patient an acknowledgement letter. Interview revealed the grievance was automatically routed to the director responsible for the area named in the grievance. Interview revealed a patient grievance regarding an ED physician would be routed to the ED Medical Director for follow up. Further interview revealed if the same patient had another grievance, that was not related to an existing grievance, the advocate would enter the information in a new grievance file. Interview revealed grievances at Hospital A should be entered into the system separately from grievances at Hospital B. Further interview revealed the advocate entered the information regarding Patient #6's grievance about her care in the ED at Hospital A into the existing grievance file regarding problems with scheduling an outpatient test at Hospital B. Interview revealed, "I knew the patient had just gone to (Hospital B). I called (Director of Service Excellence) and asked if I should enter the information into the same file because it involved some of the same issues. She said yes. She thought I had already made a new file. I made a mistake and added my information to the (Hospital B) file because there was one (a grievance) in the system that was fairly new." Further interview revealed the advocate did not send the patient a written acknowledgement of the grievance regarding her care in the ED. Interview revealed the advocate did not forward the patient's grievance regarding her care in the ED to the ED Medical Director for follow up. Interview revealed, If it had been (entered as) a separate file, it would have automatically notified the Director....The software program is set up to automatically notify the Director when a new file is entered." Interview revealed the grievance was currently closed and had not be entered into the system as a new file.

Interview on 03/08/2012 at 0920 with the Director of Service Excellence the patient's grievance regarding her care in Hospital A's ED was missed because it was entered into Hospital B's grievance file as a follow up comment, instead of as a new file at Hospital A. Interview revealed, "I told (Patient Service Advocate #1) to add it to (Hospital B's) file because when she told me about the patient's complaint she didn't tell me it was a separate issue. It was a mistake." Further interview revealed, "When we became aware yesterday we forwarded the process. We requested (physician) peer review."

Interview on 03/07/2012 at 1530 with the Medical Staff Services Director revealed usually a grievance related to an ED physician was automatically e-mailed to the Director, at which time she forwarded the information to either the ED Medical Director or ED Assistant Medical Director for physician peer review. Interview revealed the Director did not receive an e-mail about Patient #6's grievance. Interview revealed the Director became aware of the grievance as a result of the current survey. Interview revealed, "I think (the Chief Nursing Officer) told me about this grievance today....I just referred it for peer review today....(The ED Assistant Medical Director) reviewed the case today."

NC00077478