HospitalInspections.org

Based on a review of documentation and interview with staff, it was determined that the facility failed to review and provide prompt grievance resolution per hospital policy for 1 of 1 patient whose record was reviewed.

Findings were:

A review of of policy HOSP 205 stated: "Procedure; The person receiving the complaint shall complete an Incident Report. The hospital shall review, investigate, and resolve each patient's complaint within a reasonable time frame. The facility CEO or their designee shall provide the patient with a verbal or written response within 3 business days of receipt of the complaint and shall maintain communication as needed until the point of resolution." No documentation was found by or provided to the surveyor to indicate that the faciltiy had addressed the concerns raised by the family of patient #1.

In an in-person interview with the facility's CQO on the morning of 02/21/12, it was confirmed that the family of patient #1 had raised concerns about quality of care on 11/01/2010 and that these concerns had been raised directly to the CQO. In the same interview, it was also confirmed that the facility policy is to complete an incident report and that the facility had failed to complete this report. Upon request by the surveyor there was no documentation provided to indicate that the facility had completed an incident report as required by the facility's own policy.