HospitalInspections.org

Based on review of hospital documents and interviews with hospital staff, the facility failed to establish and enforce a process for prompt resolution of patient grievances. This occurred in one (Patient #2) of three grievances reviewed.

Findings:

1. Although the facility had a grievance policy, the policy did not define grievances as defined by Center for Medicare & Medicaid Services (CMS) so the grievance was handled as a complaint.

2. On the morning of 10/31/2011 surveyors were handed a folder that contained complaint /grievance reports. Patient #2 had a complaint/grievance form that contained a family member that made a complaint about patient #2's nursing care on the night of 9/17/2011. The complaint /grievance form was filed on 9/19/2011. The complaint/grievance form was not completed and signed by staff B until 10/19/2011, one month after the grievance was filed.

a. The report did not appropriately identify the patient's issue as a grievance. Because the issue was not resolved at the time it was voiced and needed investigation, it became a grievance.

b. The facility failed to provide any information or evidence that there was an investigation conducted to resolve the patient grievance. This was discussed with staff B on the afternoon of 10/31/2011 and staff B had nothing further to add.

3. This was discussed with administration on 10/31/2011. The administrative staff stated that they had not recognized the difference between a complaint and grievance.

Based on review of hospital documents and interviews with hospital staff the facility failed to follow their policy concerning the review, investigation, and resolution of grievances. This occurred in one out of three reports selected for review.

Findings:

1. The facility states in their policy that a grievance will be resolved in seven days.

2. Patient #2's family member filed a grievance with the facility on 9/19/2011 in regards to the nursing care the patient received on the night of 9/17/2011. Staff B did not address the grievance with the family until one month later on 10/19/2011. There was no documentation or evidence that a written response was ever presented to the complainant or that resolution had occurred.

3. This was discussed on 10/31/2011 with administration.