HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility failed to ensure a written response letter was provided to the patient/patient representative providing information to address appropriate and reasonable actions taken on the patient's behalf to resolve their grievance. 4 of 6 patients did not receive grievance letters to include the appropriate and reasonable actions taken to resolve the patient's grievance.

Findings were:

Review of patient medical records, on 6/15/17 from 10:00 a.m. to 4:00 p.m., revealed grievance resolution letters were not sent to patients #1, 3, 4, and 5 post complaint investigation as per facility policy.

Review of facility policy titled "Patient Complaint/Grievance Process" states in part "The Hospital maintains a procedure for systemic resolution of complaints and grievances, including 1) solicitation of concerns; 2) intervention to address these concerns; 3) escalation of the issues that are not easily resolved to appropriate supervisors or staff; 4) notification; 5) related documentation; 6) response; 7) reporting/tracking and trending through the hospital's Quality Assurance and Performance Improvement (QAPI) program."
"Responding to Grievances:
a. Call the complainant to discuss the results of the investigation and the actions taken to resolve the grievance.
b. Ask the complainant if they consider the matter resolved.
* If the complainant considers the matter resolved:
1. Write or review (if prepared by the DQM) the CEO letter
2. Sign and send within 7 days of the complaint.
* If the complainant DOES NOT consider the matter resolved:
1. Contact the SDCO or SDRM immediately.
2. Prepare the "CEO Bridge Letter" after consultation.
3. Sign and send within 7 days of the complaint.
4. When a final resolution is accomplished:
a. Prepare the final "CEO Letter"
b. Sign and send immediately after resolution is accomplished.
5. When a final resolution is unobtainable:
a. Prepare the final "CEO Letter" with consultation of the SDCO and SDRM. They may recommend that the response may be referred for legal counsel review prior to sending.
b. State that the isssue will now be closed due to conclusion of a thorough investigation.
c. Summarize the efforts to resolve the matter.
d. Sign and send as soon it has been determined that resolution will not be obtainable.
NOTE: It is acceptable for the CEO to designate and direct a representative (i.e., DQM, CCO, Department Head or other appropriate person) to prepare the CEO letter or contact the complainant when resolving a grievance."

In an interview with the Director of Quality Management and the Chief Executive Officer on 6/15/17 both acknowledged the facility did not send a resolution or response letter to the patient's representative as per policy. Both stated the matter for patient #1 had been referred to the Compliance Department and they did not consider the family complaint and request for further information a grievance or complaint.