HospitalInspections.org

Based on staff interview and document review it was determined the hospital failed to follow their complaint policy in one (1) of one (1) complaint not investigated (patient #1). This failure has the potential for all patients/families that have a complaint to not have their concerns investigated.

Finding include:

During entrance on 11/7/22 at approximately 8:10 a.m., the Administrative Assistant (AA) to the Chief Executive Officer (CEO) acknowledged they were aware of the complaint. When asked to provide a copy of their notes and investigation, they stated in part, "I will get my notes but I didn't investigate it."

An interview was conducted with the Behavior Health Unit (BHU) Nurse Manager (NM) on 11/07/22 at 11:20 a.m. in the presence of the Vice President of Quality. When asked if they filed a complaint on behalf of the spouse, they stated, "No, I felt it was an educational experience." When asked if the spouse told them during his complaint that they were going to file a malpractice lawsuit and a civil lawsuit against the hospital, and why they didn't file a complaint on the spouse's behalf, they stated in part, "I felt this was an educational experience for the spouse to help him learn our process. I can see now that I should've filed a complaint."

An interview was conducted with the AA to the CEO on 11/7/22 at 12:30 p.m. When asked to explain why they never filed a complaint when patient #1's spouse called the hospital complaining of keeping the spouse against their will, suing for malpractice, filing a civil lawsuit, and a possible breach of patient information, they stated, "When I got off the phone I called [states BHU NM's name] and explained the spouse's concerns." When asked again if they filed a formal complaint, they stated, "No."

A telephone interview was conducted with Patient Advocate #1 on 11/07/22 at 1:10 p.m. When asked if they received a complaint filed for a patient who was a voluntary admission that felt like they were being held illegally against their will, they stated, "No, that does not sound familiar to me."

A review of a handwritten document that was written by the AA to the CEO, states in part: "Volunteer [admission] on 7C understanding that they could leave at any time here 3-7 days to get therapy ... They forced them for signature they did not read the form ... They will not let them leave ... The more you struggle the longer you will stay ... 27-4-2 meets the criteria to leave ... [states NM name] told the spouse that [patient #1] shows no signs of suicidal ideations and is not a harm to others."

A review of the policy titled "Complaint and Grievance Management & Patient Satisfaction," last reviewed 07/22, states in part: "A 'complaint' is a problem that is voiced by a patient where a patient issue can be resolved promptly by staff present ... Patient and visitors may express a concern or a complaint by either verbal or written communication directly with any UHC [United Hospital Center] employee or by contacting risk manager. i) Any UHC employee receiving a complaint will complete a 'Patient Complaint Form' ... Department Managers upon receiving a Patient Complaint form will: Investigate the complaint, which will usually include contacting the patient."

An interview was conducted with the Vice President of Quality on 11/07/22 at 2:00 p.m. They concurred that no complaint or investigation occurred as a result of the complaint.

Based on staff interview, record review and document review it was determined the Behavior Health Unit (BHU) Nurse Manager (NM) failed to ensure one (1) of one (1) patient's information was protected (patient #1). This failure has the potential for all patients who enter the facility to have their private patient information released.

Findings include:

An interview was conducted with the BHU NM on 11/07/22 at 11:20 a.m. in the presence of the Vice President of Quality. When asked if they told the spouse the patient had no signs of suicidal ideations or was a harm to others, they stated in part, "Yes, I did tell them that."

A review of the medical record for patient #1 revealed upon admission the patient was asked: "Do you want your family/representative notified of your admission?" The patient answered, "No." When asked if they wanted to appoint a lay caregiver, they declined.

A review of the policy titled "Confidentiality of Protected Health Information for Patients and Employees," last reviewed 10/20, states in part: "Patients shall be given consideration as it relates to confidentiality of their medical and personal information via any mode of communication. UHC employees shall take, at a minimum, the following steps to maintain protected health information ... Talk about patient condition in a private place, If authorized to give out the information by the patient ... When approached by a visitor/person, initially only make general comments (can state if patient is located on unit or not) ... Protection of sensitive information: Behavior Health information No information may be released regarding a Behavior Medicine patient without account order or as directed by law. Even the fact the person is or was a patient is confidential."

An interview was conducted with the Vice President of Quality on 11/07/22 at 2:00 p.m. They concurred the patient's medical information should not have been given to the spouse by the NM.