Patient Complaints/Grievences

Patient Complaints Grievances

PURPOSE:  Cumberland Healthcare shall promptly investigate, resolve, and create actionable preventive steps related to any reported incidents, complaints, or grievances. 

Incident, Grievance, and Complaint reporting in health care has been advocated as a means to improve patient safety and satisfaction. The purpose of reporting is to identify safety hazards, non-optimal care, and complaint trends and use qualitative data to develop interventions to mitigate these in order to reduce harm and improve the quality and satisfaction of care delivered. This policy defines the process for responding to patient care concerns or grievances in a consistent and timely manner.

Each patient admitted to this facility shall receive a Grievance/Complaint Process Notice at the time of admission to the facility within the Patient’s Rights and the General Consent to Treat.

POLICY: Cumberland Healthcare provides an avenue for communicating concerns or grievances as they pertain to patient care.


Incidents, complaints, and grievances can come from inpatients, outpatients, discharged patients, or a patient’s representative regarding the patient care provided.

  • An incident is an unintended or unexpected event that harmed or had the potential to harm a patient or caregiver.
  • A grievance is a formal or informal, written or verbal, complaint that is made to the hospital by a patient or the patient’s representative regarding the patient’s care. “Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee…”. All written complaints, verbal complaints unable to be resolved within 48 hours, or verbal complaints regarding the safety of a patient are considered a grievance.
  • A complaint is an informal verbal complaint that is made to the hospital by a patient or the patient’s representative regarding the patient’s care that does not impact patient safety or immediate care (care occurring at that moment in time). The complaint is acknowledged and discussed with the individual at the time it is made. If it can be resolved at that time, no additional follow-up with the individual filing the complaint is necessary. If the complaint can be resolved within 48 hours, a phone call or in-person conversation regarding resolution is appropriate.
  • However, a written complaint is always considered a grievance including but not limited to an email, fax, and if a patient writes or attaches a complaint on a written survey and identifies him/herself. Additionally, if the individual filing the complaint states “I want to make an official complaint” or “grievance” or version of this statement, the complaint will be moved to a grievance status within the reporting system and follow all grievance processes.


 Registration and disposition of patient incidents/grievances/complaints can be made without threat of discharge or other reprisal against the patient or staff member. All attempts to resolve the incident/grievance/complaint will be made.

  1. Any concern or grievance regarding the rights of a patient or any other situation regarding the operation of Cumberland Healthcare shall be addressed to the following staff.
    1. A member of the Senior Leadership Team
    2. The Unit or Department Supervisor
    3. Charge Nurse

The staff noted above will log the incident in Meditech (EMR Incident Tracking System). The details of the incident, review, and follow-up will be noted in the system using the Complaint/Grievance Incident Type and Event Code – select Complaint or Grievance.

  1. After receiving a concern or grievance, the Administrator or Director of the department will follow up with the employee or situation, and an action plan will be implemented.
    1. Complaints will be addressed immediately and resolved within 48 hours.
    2. Grievances will be addressed within 7 days and resolved within 30 days.

Documentation of the corrective action will be sent to the Administrator and should include who followed up with the patient or representative, when, and what outcome occurred.

  1. Each patient or representative making a grievance will receive a timely response from Cumberland Healthcare that substantively addresses the complaint. Once the review is complete, follow-up with the individual providing the incident/grievance/complaint will occur.
    1. If the issue is an incident identified by an employee, the findings will be recorded in the system and no additional formal written follow-up will be sent. Informal follow-up will occur directly back with the employee upon completion of the case analysis.
    2. If the complaint is resolved within 48 hours no further action is required beyond a verbal follow-up. However, if circumstances are severe or the complaint is in regard to patient safety, the team member can escalate the complaint to a grievance within the incident reporting system’s event severity.
    3. If the issue is a grievance (a concern brought by a patient or representative that cannot be closed within 48 hours, states it is an official complaint, states it is a grievance, or the complaint revolves around patient safety) the grievance must be acknowledged within 7 days through written communication (letter, email, fax, etc.) and include the next steps in the process. The grievance must be resolved within 30 days and communicated in writing to the individual filing the complaint.

The written response will include a hospital contact person, a summary of the concern, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

  1. All grievances are reviewed by Senior Leadership through the Meditech System to ensure compliance with this policy and procedure.
  2. If the situation warrants service recovery action, the administrator or department director will initiate the appropriate action per the Customer Service Recovery Program.
  3. Cumberland Healthcare assures all patients of quality health care. Patient care will not be compromised to those individuals who have filed concerns or grievances in the past. If a concern or grievance cannot be resolved to the patient’s satisfaction, they may contact the hospital Administrator.

When addressing any of the above-mentioned staff in written form, correspondence should be addressed to:


Patient Grievance Cumberland Healthcare

1705 16th Avenue

Cumberland, WI 54829


Division of Quality Assurance Kepro  The Joint Commission

Department of Health Services

PO Box 2969

Madison WI 53701-2969

5700 Lombardo Center Dr.

Suite 100

Office of Quality Monitoring One Renaissance BLVD

Phone (608) 267-7185

Seven Hills OH 44131

Oakbrook Terrace, IL 60181


Phone 1-800-994-6610

References: § 485.614 Condition of participation: Patient‘s rights.