HospitalInspections.org

Based on review of records, interviews with staff, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Eleven incidents or complaints identified in the complaint/grievance log and incident reporting met the definition of a grievance. There was no evidence the hospital identified the events as grievances. There was no documentation the events were reviewed through the grievance process.

Findings:

1 On 3/12/2012 surveyors reviewed the facility complaint and grievance log. Several concerns listed required investigation and could not be resolved at the time the concerns were voiced. There was no documentation these complaints were identified as grievances. The facility failed to identify grievances.

2. On 3/12/2012 Staff C identified as the grievance coordinator told surveyors he reviews the complaint/grievance log Monday, Wednesday, and Friday. Staff C also told surveyors the staff member present identified if the event was a complaint or grievance. Staff C told surveyors if the event was considered a complaint the complaint was usually given to the department manager to review and follow. Staff B and C indicated most all complaints are reviewed daily in a leadership meeting but there are no minutes taken at this meeting.

3. The above findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion were provided to the complainants. Two of the two grievances reviewed did not include a written response with all required elements to the complainants.