Grievance Policy

Call Us: 575-437-0890

Grievance Process (2020)

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PURPOSE: To ensure a process for the documenting the existence, submission, investigation, and disposition of patients written or verbal grievance to the ASC.


TYPES: All alleged violations, grievances relating but not limited to mistreatment, neglect, verbal, mental, sexual, or physical abuse will follow the below protocol. 

RECEIVING GRIEVANCES: The Facility Administrator or designated individual will be responsible for initiation of the process for all patient grievances once made aware.  All allegations must be immediately reported to the Administrator. The ASC, in responding to the grievance, must investigate all grievances made by a patient or the patient’s representative, or the patients surrogate, regarding treatment or care that is (or fails to be) furnished. Patsey Bridges 2301 Indian Wells Rd. Suite B Alamogordo, NM, 88310(575) 437-0890.

INCIDENT REPORT: An incident report for every grievance will be written. 

GRIEVANCE PACKET: If the facility is notified directly, the patient and or representative will be given a "grievance packet" which includes the policy and a patient grievance form by the Facility Administrator or designated individual.

PATIENTS RIGHT TO FILE: Patients have a right to file complaints with the Facility administrator and with the government. These governmental facilities may be accessed directly without notification to the Facility Administrator. Employees of the Surgery Center must act cooperatively with patients who wish to file a complaint. The Surgery center cannot intimidate, threaten, coerce, or take any retaliatory acts against the patient for filing a complaint with the Surgery center and/or government. To report formal grievances directly:

  • The contact information to report a complaint including contact at: ATTN: Title: Compliant supervisor at DHI Complaint Unit, PO Box 26110,Santa Fe, NM 87505, phone 505-476-9096, Fax 888-576-0012 at or the New Mexico Medical Review Association (for Medicare beneficiaries), 5801 Osuna Road NE Suite 200,  Albuquerque, NM 87109, 1-800-663-6351, To learn more about the Centers for Medicare and Medicaid Services (contact information 1-800-Medicare), If you are a Medicare beneficiary the contact information for the Medicare Beneficiary Ombudsman website is (, and I understand that the role of the Medicare Beneficiary Ombudsman is to ensure that the Medicare beneficiary receives the information and help needed to understand their Medicare options and to apply their Medicare rights and protections.

INVESTIGATION: An investigation of all electronic, clinical records, and employee and or medical staff interviews and any other pertinent information if required will be completed which will include recommendations for changes or actions taken.

LOG: A log will be maintained with a reference number, patient name, date, brief description of grievance, patient response, and changes that occurred in order to assess for trends or patterns. 

  • Only substantiated allegations will be reported to the state authority and or the local authority or both. 2. Facility Administrator 3. Medical Director 4. Quality Improvement 5. Governing Board 

REPORTING OF INCIDENT OUTCOME TO PATIENT/ REPRESENTATIVE OR SURROGATE: After filing a grievance you may expect how the grievance was addressed and written notice of the grievance and a written response within 30 days to include (but no information that breaches the confidentiality and privilege of peer review, general confidentiality of business or other health care requirements, or employee disciplinary actions shall be provided):

  • The name of a contact person
  • The decision of the Surgery Center
  • The steps taken to investigate your grievance
  • The results of the grievance
  • Any changes implemented resulting from investigation for Quality improvement
  • Date the grievance process was completed 
  • If at any time during the investigation there is a reasonable need for an extension of this time line to thoroughly complete the investigation and implement an action plan or resolution, you be notified in writing by registered mail or express delivery. That communication shall include reasons for the time extension and a final date for written response. Extensions will be used sparingly and only with extenuating circumstances and not as a matter of convenience. The time line should under normal circumstances be held as part of the Grievance Process to ensure a timely response to the patient. 
  • If you or your representative indicates dissatisfaction with the response, either verbally or in writing after resolution contact, they shall be informed that they have the right to initiate an appeal process. You or your representative will be informed that they must provide a written statement regarding the elements of dissatisfaction with the initial response and what further resolution is requested. Upon receipt of the notice of dissatisfaction, the Grievance process time line resets as the organization will have an additional 30 days. 
  • If Risk Manager is unable to make contact within the designated time, Risk Manager shall send an acknowledgement letter by registered mail or express delivery to ensure contact. 


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Southern New Mexico Surgery Center

2301 Indian Wells Rd. Suite B
Alamogordo, NM 88310

Phone: 575.437.0890
Fax: 575.437.0905