HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the hospital's grievance process was followed for 1 patient's complaint (Patient A). This had the potential for unresolved patient complaints.


Findings:

During an interview with the family member of Patient A, on 1/3/12 at 2 PM, she stated there had been a delay in performing a liver biopsy for Patient A. The delay in the liver biopsy was due to a radiologist recommendation. The patient and the family member were concerned about whether the radiologist was qualified to make such a recommendation. The family member stated Patient A, therefore; filed a complaint with the hospital's compliance officer on 12/15/11, and still has heard nothing back from the hospital.

During an interview with the Compliance Officer (CO), on 1/3/12 at 3:55 PM, she stated she was the person responsible for taking patient complaints. She took down the information regarding Patient A's complaint and then forwarded the information to the Clinical Director (CD). Patient A was a patient of the clinic and therefore she forwarded the complaint to the CD.

During an interview with the CD, on 1/6/12 at 10:55 AM, she indicated after reviewing Patient A's clinical record there did not appear to be an issue with a delay in a liver biopsy. It was determined the liver biopsy was an unnecessary invasive procedure. She received the complaint from the CO on or around 12/16/11. She then spoke to the patient before the December holiday in regards to his complaint. She instructed the patient to return to her office after his next doctor's appointment. He never returned and no further contact has been made with the patient in regards to his complaint. She stated the hospital does have a grievance process whereby a grievance form is completed, although she was unsure if the form had been completed. There was no documentation provided the CD or the CO following the hospital's grievance process or documentation when the complaint was received, by whom and the results of the hospital's process to resolve the complaint, although this was now 3 weeks since the complaint was originally received by CD from CO. There was a "CLINIC NOTE" dated 1/4/12, by the patient's attending physician which indicated the following, "I told the patient he does not need liver biopsy..."

The hospital's policy and procedure titled, "Patient Complaint and Grievance Process", effective 2/24/11, was reviewed on 1/6/12. The policy statement indicated, "This organization shall respond to such concerns in a timely, reasonable and consistent manner..." Under the procedure subheading it read in part, "C. Staff receiving the verbal complaints should attempt to resolve the issue when possible at the time the complaint is received. If the complaint cannot be resolved at the time the complaint was received, the staff member shall notify the Department Director/Coordinator, House Supervisor or Chief Compliance Officer via the on-line complaint form...G. If not immediately resolved, the person responsible for follow-up, i.e., Department Director or Chief Compliance Officer shall investigate the complaint/grievance...K. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 72 hours...L. If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the hospital shall send a response to the patient stating that the hospital continues to work to resolve the complaint and the hospital will follow-up with another response within 10 business days..."