HospitalInspections.org

Based on record review and interviews, the hospital failed to provide a written notice to the patient and/or patient's representative that included the results of the grievance process and the date of completion of the grievance process for 1 of 2 (#3, Consumer) patients with grievances out of the total sample of 5 patients.
Findings:
Review of the hospital's policy titled "Complaint/Grievance Process," Policy Number 11-4.0.0, issued 10/11, and presented as the current policy for the grievance process by S2Assistant Administrator, revealed, in part, "The hospital's Administrator/Assistant Administrator will be responsible for the review, investigation and resolve of all patient grievances. In its resolution of the grievance, the hospital will provide a *written response of its decision within 10 days. The written response will identify the Administrator/Assistant Administrator as the contact person, the steps that will be taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion of the process. If the patient, or the patient's representative, remains unsatisfied with the hospital's actions after the written notice, the hospital will continue to make efforts to resolve any issues and to document these efforts."
Patient #3
Patient #3 was a 77-year-old female admitted to the hospital on 02/04/13 with the diagnoses of status post left hip surgery, end-stage Alzheimer's disease, severe protein malnutrition, hypotension, and urinary tract infection.
Review of the Grievance Log and its investigation revealed a grievance was filed with the hospital on 03/01/13 by the Complainant on behalf of Patient #3, and an investigation had been conducted.
Review of a letter dated 03/04/13 from S2Assistant Administrator to the Complainant revealed, in part, the internal grievance procedures had been initiated, and formal interviews with staff members, administrative members, and the Medical Director had been conducted in addition to a thorough review of Patient #3's medical record. Review of the letter also revealed that the findings of the investigation would be included in the Safety/Risk Management report and presented to the Safety and Medical Executive Committees. Further review of the letter revealed no information regarding the results of the grievance process and no information regarding the date of completion of the grievance process.
In a face-to-face interview on 08/23/13 at 10:00 a.m., S2Assistant Administrator indicated that the letter sent to the Complainant dated 03/04/13 was the only written response sent to the Complainant regarding the grievance for Patient #3. He also indicated a few attempts had been made by the administrative staff to contact the Complainant to discuss the results of the investigation by leaving messages on voice mail, and the Complainant did not return any calls. S2Assistant Administrator agreed the letter dated 03/04/13 to the Complainant did not contain information regarding the resolution of the grievance process or the date of completion of the grievance process.