HospitalInspections.org

Based on staff interview and hospital policy, it was determined the hospital failed to ensure the grievance process provided specific direction and time frames for a written response to each grievance. This resulted in a lack of clarity for staff and patients about the grievance process. Findings include:

During a tour of the facility on 10/04/11 at 8:45 AM, a poster titled "Grievance Process," was observed to be posted in the hallway near patient rooms. The process did not include a time frame for providing patients written responses to grievances. The hospital's policy, "GRIEVANCES/COMPLAINTS," dated 9/13/11, was consistent with the posted information.

The Administrator was interviewed on 10/05/11 at 12:50 PM. He stated he thought the hospital's policy designated a time frame for providing a written response. He then reviewed the hospital's grievance policy and acknowledged it designated a time frame for an oral response but not a written response.

The hospital's grievance policy did not include a time frame for written responses to patient grievances.

Based on review of hospital policies and grievance information, and interviews with staff and patients, it was determined the hospital failed to ensure the hospital's grievance process included the expectation the hospital would provide written notice to patients that included required elements. This impacted 1 of 1 patient (#7) whose grievance was reviewed and had the potential to impact the clarity of resolution of grievances for all patients who filed grievances. Findings include:

The facility was toured on 10/04/11 at 8:45 AM. A poster titled "Grievance Process," was observed to be posted in the hallway near patient rooms. The information on the poster included an expectation that the Administrator or his designee would respond orally to patient grievances within 3 working days. It also stated a written summary of the report would be provided to the patient. It did not state what information would be included in the written response, such as the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital's policy, "GRIEVANCES/COMPLAINTS," dated 9/13/11, was consistent with the posted information.

On 10/04/11, surveyors requested to view the grievance log for all grievances filed since 9/25/11. The Administrator provided surveyors with a single grievance completed by Patient #7. He stated no other grievances had been filed since 9/25/11.

Patient #7's grievance, dated 9/30/11, alleged the hospital did not provide adequate amounts of food at mealtime and did not allow seconds. Patient #7 was interviewed on 10/04/11, at 10:00 AM. She confirmed she filed a grievance about inadequate portions of food during mealtime. She stated staff had not yet responded to her grievance.

The Administrator was interviewed on 10/04/11 at 2:40 PM. He stated he had talked to Patient #7 about her grievance and told her additional food was available upon request. He confirmed the grievance process did not include the required elements for a written response to grievances and that he had not responded to Patient #7 in writing.

The hospital's grievance process was incomplete and the hospital did not respond in writing to a patient grievance.

Based on staff interview and review of the QAPI plan, it was determined the hospital failed to ensure the QAPI plan included a hospital-wide scope. This resulted in an underdeveloped QAPI program and had the potential to result in missed opportunities for performance improvement. Findings include:

The undated "QUALITY ASSESSMENT PROCESS IMPROVEMENT PLAN," did not address the scope of the plan or make clear QAPI activities would be hospital-wide, including performance improvement projects.

The Administrator and DNS were interviewed together on 10/05/11 at 12:00 PM. They explained the hospital's current PI project revolved around efforts to reduce the use of prn medications. The Administrator stated he thought they were only required to have one performance improvement project at a time. He did not realize he needed to involve all departments of the hospital in performance improvement.

The hospital did not ensure the QAPI plan met scope requirements.