HospitalInspections.org
Bringing transparency to federal inspections
KPC PROMISE HOSPITAL OF DALLAS
PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES
Tag No.: A0120
Based on record review and interview the hospital's governing body failed to be responsible for the effective operation of the grievance process in that the hospital failed to follow it's complaint and grievance process for 2 of 2 (Patient #8 and Patient #9) patients that filed a grievance with the hospital.
Findings included:
The facility received a complaint on 10/23/2020 regarding the care of Patient #8. The complaint was received from another hospital after the patient had already left the facility. This should have been filed as a grievance since the concern could not have been resolved promptly by staff present at the time of the occurrence. The facility did not did not send the required letter within seven days. The facility had spoke to the complaint on 11/09/20 and sent an email to the complainant on that day. The complaint still had not been finalized as of 02/02/21 and no additional letters had been sent to the complainant.
The facility received a grievance on 10/26/20 from Patient #9 The facility did not respond to the complainant with a letter until 11/10/20, 15 days after the grievance was received.
During an interview on 02/02/21 at 1225 with Personnel #1 and Personnel #3 in the Conference, both Personnel #1 and #3 agreed the facility was not following the complaint and grievance policy.
The policy titled Complaint/Grievance Process revised on 10/01/13 reflected..."Definition...Grievance: Written or verbal requests by patient or designated representative to have...review the patient's concerns. Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance. This concern cannot be resolved promptly by staff present at the time of the occurrence...Procedure...Upon receiving the grievance report, the facility DQRM (director of quality risk management): a. Reviews the grievance report and responses to the originator of the concern in writing that their grievance has been received and is being investigated...A 'follow-up' response is provided to the patient or patient's representative within seven days of the report..."