HospitalInspections.org

Based on review of policies and procedures and interview, it was determined the Facility failed to assure the policies and procedures included a process for submitting a grievance in writing. Lack of a process for the submission of a written grievance did not assure patient rights would be protected. The failed process affected the census of nine patients and was likely to affect any patient admitted to the Facility. The findings were:

A. Review of the policy and procedure "Grievance Process" on 11/26/13 at 1015 revealed no process for filing a written grievance. The policy stated "A grievance is filed with the Director of Nursing".

B. The findings were confirmed by interview with the Director of Nursing on 11/25/13 at 1230.

Based on review of policies and procedures and interview, it was determined the facility failed to assure policies and procedures included a process for review of grievances within time frames to allow for investigation and response to the patient. Failure to have a process for review and response did not assure patient rights would be protected. The failed process affected the census of nine patients and was likely to affect any patient admitted to the Facility. The findings were:

A. Review of the policy and procedure "Grievance Process" on 11/26/13 at 1015 revealed, "within 30 days of the filing of a grievance, the Hospital will provide the patient or visitor with a written notice of its decision."

B. The findings were confirmed by interview with the Director of Nursing on 11/25/13 at 1230.