HospitalInspections.org

Based on policy review, document review and staff interview it was determined the facility failed to ensure the written complaint/grievance policy was followed for six (6) of ten (10) complaints/grievances reviewed (complaints #1, 2, 3, 5, 6 and 10). This failure has the potential for patients to have their rights violated when there is an ineffective complaint/grievance process.

Findings include:

1. Review of the hospital policy, "Patient Complaint and Grievance Process", effective 4/2014, revealed the policy states, in part: "The Hospital Quality Improvement Committee ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within seven (7) days of the Hospital's receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit...If the grievance is not yet resolved within the initial, written response of seven (7) days, the written response will indicate that the hospital is working towards a resolution of the grievance and that a follow-up written response will be provided within a specified time period but not to exceed thirty (30) days until the grievance is resolved. If the grievance remains unresolved after thirty (30) days, additional written follow-up would be indicated within a specified time period but not to exceed an additional thirty (30) days."

2. Selected documented complaints/grievances which were documented via a computerized system and via a paper system were reviewed for a time period of one (1) year previous to the investigation.

Review of complaint #1 revealed the complaint was made on 8/7/14. The only written response was dated 9/12/14, prior to the completion of the investigation, and after the required timeframe to respond with seven (7) days. There was a note on the file the complaint was sent to the Emergency Department physician for review on 8/14/14, 9/3/14 and 10/8/14. There was no written response by the physician indicating the patient's complaints had been investigated. There were no further written responses to the complainant documented in the file.

The above file was reviewed with both the Risk Manager and the Quality Coordinator on 7/28/15 at 10:20 a.m. and they concurred with the findings.

3. Review of complaint #2 revealed the complaint was made on 9/5/14. The investigation notes were incomplete and there was no evidence any letter had been sent to the complainant.

The above file was reviewed with both the Risk Manager and the Quality Coordinator on 7/28/15 at 10:20 a.m. and they concurred with the findings.

4. Review of complaint #3 revealed the complaint was made on 9/16/14. The first letter was sent on 9/25/14, later than the required seven (7) days. Also, the complaint was forwarded to the physician for review and there was no documented response from the physician. There were no further letters sent to the complainant.

The above file was reviewed with both the Risk Manager and the Quality Coordinator on 7/28/15 at 10:20 a.m. and they concurred with the findings.

5. Review of complaint #5 revealed the complaint was made on 10/14/14. The investigation was completed and documented. There was no evidence any letters were sent to the complainant.

The above file was reviewed with both the Risk Manager and the Quality Coordinator on 7/28/15 at 10:20 a.m. and they concurred with the findings.

6. Review of complaint #6 revealed the complaint was made on 2/23/15. The investigation was completed and documented. There was no evidence any letters were sent to the complainant.

The above file was reviewed with both the Risk Manager and the Quality Coordinator on 7/28/15 at 10:20 a.m. and they concurred with the findings.

7. Review of complaint #10 revealed there was a "paper" file only and the file was not dated. Notes were made and a copy of the patient's medical record was included in the file. It was noted the complaint was forwarded to the Director of Nursing for review and response. There was no documented review or evidence of a written response in the file.

The Risk Manager was interviewed on 7/29/15 at 8:30 a.m. She stated the complaint had been made sometime in November 2014, and she had forwarded the complaint to the Director of Nursing the same date.

The Quality Director was interviewed on 7/28/15 at about 4:00 p.m. relative to the complaint and she stated there was no other documentation of any investigation or response available for review and she was unable to confirm the complaint was investigated or responded to.