HospitalInspections.org

Based on interview and record review, the facility failed to provided written notice of the investigative findings and completion of a grievance for 1 (P-8) of 3 grievances reviewed, resulting in unmet patient rights for written communication response. Findings include:

Medical record review revealed that P-8 was a 45-year-old female who had a total abdominal hysterectomy, bilateral salpingo-oophorectomy (removal of uterus, fallopian tubes, and ovaries) and lysis of adhesions. This surgery was performed last year on 5/8/24 due to an abdominal mass. The patient was discharged on 5/11/24 with a scheduled post-operative follow-up on 5/15/24. The patient presented to the emergency department due to increased vaginal bleeding on 5/19/24 and had surgery to close the vaginal cuff. The patient was discharged on 5/21/24. The patient had post-operative follow-up visits on 6/5/24, then on 8/20/24.

Record review revealed that on the 8/20/24 post-operative visit, the patient complained to the surgeon and the office manager that she had been penetrated by something after the first surgery on 5/8/24. The patient believed she was assaulted.

On 3/24/25 at approximately 1300, interview with the Regional Director Accreditation (Staff B) revealed that the Departments of Risk Management and/or Public Safety/Security handle allegations of possible abuse. Staff B also stated that the Department of Patient Relations handled (minor) complaints, not allegations of abuse.

Interview with Security Officer/Investigator (Staff O), on 3/24/25 at approximately 1400, revealed that he had done the investigation and could not substantiate the allegation. Staff O also stated that he reported his findings to his manager, but was not responsible for sending findings to the complainant. Staff O had his written report available to review.

On 3/24/25 at approximately 1430, interview with the Risk Manager (Staff K) and Risk Management Director (Staff L) revealed that a letter of investigative findings had not been sent to the patient. Staff L stated that the process had changed and the informational findings letter to the patient was errantly missed.

Interview with the Office Manager (Staff M), on 3/24/25 at approximately 1530 revealed that she had reported the allegation to the hospital Risk Manager and entered the allegation in the facility incident reporting system. Staff M stated that she received a call from Risk Management staff informing her that the process had changed and that the Security Office/Department of Public Safety would handle the investigation.

Review of the facility policy titled "Complaint and Grievance Management, revised 3/20/25 (previous edition dated 1/5/22)" documented, "Investigation and Conclusion... However, in all cases Patient Relations & Clinical Risk must provide a written notice (response) to each patient grievance(s). This had not been done.