HospitalInspections.org

Based on facility grievance file review, hospital policy and staff interview (A), the hospital failed to ensure that written decision notice information was provided to 5 of 6 patient complainants (Pts. 1, 2, 3, 4, 5) and that the written notice contained the required notice information. This occurred in a total of 6 grievances reviewed, in a total sample of 18 patients; having the ability to affect the total hospital census of 25 patients.

Findings include:

In the 3/5/14 interview with QA Director A at approx. 11:45 a.m., A was asked to provide resolution timeframes for randomly selected sampled patients filing hospital grievances, documented on the hospital patient complaint log.

Policy No. COL-1019, effective 3/1/07 and revised 1/2014, states under "E. In its resolution of complaints, the hospital provides the individual (complainant) with a written notice of it's decision within 30 days which contains the following: the name of the hospital contact person, the steps taken behalf of the individual to investigate the complaint, the results of the process, and the date of completion of the complaint process."

The 3/5/14 at 1 p.m. review of the above selected complaints for Pts. 1, 2, 3, 4, and 5 show no complaint response letters were written to these complainants after the facility investigations were completed.

In interview with A at 1:15 p.m. on 3/5/14, A stated that the process would have to be changed.