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FAIRMONT REGIONAL MEDICAL CENTER 1325 LOCUST AVENUE FAIRMONT, WV 26554 March 27, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and staff interview, it was determined the facility failed to follow hospital policy by providing written notification to the patient of its investigation following submission of a grievance in six (6) of six (6) complaint files reviewed (Patients #1, #2, #3, #4, #5 and #6). This failure has the potential to deny the rights of all patients submitting grievances by leaving them unaware of the outcome of the hospital investigation.

Findings include:

1. The facility policy entitled "Patient Complaint/Grievance Management and Procedure", last revised 11/13, was reviewed on 3/25/14. It states, in part, under the heading "Procedure: F) 3) In its resolution of the grievance, the hospital will provide the patient with written notice of its decision that contains the name and phone number of the Patient Advocate, the steps taken on behalf of the patient to investigate the complaint, the results of the investigation and the date of completion as indicated by the date of the letter."

2. The complaint file of Patient #1 was reviewed with the Director of Quality Assurance (QA) on 3/25/14 at 1330. It revealed, in part, a copy of a letter sent to the patient following the conclusion of the investigation. The Director of QA agreed that the letter did not contain any information about the steps taken to investigate the complaint or the results of the investigation.

3. The complaint file of Patient #2 was reviewed with the Director of Quality Assurance (QA) on 3/26/14 at 1200. The Director of QA agreed that no written notification to the patient following an investigation was present in the file.

4. The complaint file of Patient #3 was reviewed with the Director of Quality Assurance (QA) on 3/26/14 at 1200. The Director of QA agreed that no written notification to the patient following an investigation was present in the file.

5. The complaint file of Patient #4 was reviewed with the Director of Quality Assurance (QA) on 3/26/14 at 1200. The Director of QA agreed that no written notification to the patient following an investigation was present in the file.

6. The complaint file of Patient #5 was reviewed with the Director of Quality Assurance (QA) on 3/26/14 at 1200. The Director of QA agreed that no written notification to the patient following an investigation was present in the file.

7. The complaint file of Patient #6 was reviewed with the Director of Quality Assurance (QA) on 3/26/14 at 1200. The Director of QA agreed that no written notification to the patient following an investigation was present in the file.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and staff interview, it was determined the facility failed to follow hospital policy regarding expected time frames for communication with the patient following submission of a grievance, in six (6) of six (6) complaints reviewed (Patients #1, #2, #3, #4, #5, and #6). This failure has the potential to deny the rights of all patients registering complaints at this facility to a prompt response to their concerns.

Findings include:

1. The facility's policy entitled "Patient Complaint/Grievance Management and Procedure", last revised 11/13, was reviewed on 3/25/14. It states, in part, under the heading "Procedure: F) A response will be given to the complainant within 72 hours of receiving complaint. This may only include that the investigation has begun and state in general terms the time frames for resolution. The contact will be documented on the 'Initial Patient Complaint Form'. 1) Within 7 days, a written notification will be sent to the patient or patient's representative indicating the steps being taken to resolve the complaint or indicating resolution of the complaint".

2. The complaint file of Patient #1 was reviewed with the Director of Quality Assurance (QA) on 3/25/14 at 1330. It revealed, in part, the complaint was lodged by the patient on 12/16/13. It revealed a handwritten note, of the first telephone contact with the patient following the receipt of the complaint on 1/8/14. A copy of the letter sent to the patient following the investigation of the complaint was reviewed and revealed a date of 1/29/14. The Director of QA agreed that the time frames defined in hospital policy had not been met.

3. The complaint file of Patient #2 was reviewed with the Director of QA on 3/26/14 at 1200. It revealed, in part, hand-written documentation of the receipt of the complaint on 9/30/13. No documents were found to indicate the patient had been contacted within seventy-two (72) hours of the complaint, that an investigation had been initiated to date, or a response had been provided to the patient within seven (7) days. The Director of QA agreed that the time frames defined in hospital policy had not been met.

4. The complaint file of Patient #3 was reviewed with the Director or QA on 3/26/14 at 1200. It revealed, in part, documentation of receipt of the complaint on 10/3/13. No documents were found to indicate the patient had been contacted within seventy-two (72) hours of the complaint. No documents in the file were found indicating a response to an investigation had been provided to the patient within seven (7) days. The Director of QA agreed the time frames defined in the policy had not been met.

5. The complaint file of Patient #4 was reviewed with the Director of QA on 3/26/14 at 1200. It revealed in part, receipt of the complaint on 10/7/13. No documents were found to indicate the patient had been contacted within seventy-two (72) hours of the complaint or a response to an investigation had been provided within seven (7) days. The Director of QA agreed the time frames defined in the policy had not been met.

6. The complaint file of Patient #5 was reviewed with the Director of QA on 3/26/14 at 1200. It revealed, in part, a hand-written note, of receipt of the complaint on 9/30/13. No documents were found to indicate the patient had been contacted within seventy-two (72) hours of the complaint or a response to an investigation had been provided to the patient within seven (7) days. The Director of QA agreed that the time frames defined in hospital policy had not been met.

7. The complaint file of Patient #6 was reviewed with the Director of QA on 3/26/14 at 1200. It revealed, in part, a hand-written note, of receipt of the complaint on 10/10/13. No documents were found to indicate the patient had been contacted within seventy-two (72) hours of the complaint or a response to an investigation had been provided to the patient within seven (7) days. The Director of QA agreed that the time frames defined in hospital policy had not been met.