HospitalInspections.org

Based on interview and record review, the facility failed to respond to a grievance in a timely manner for 1 of 3 patients (#2) reviewed for the grievance process resulting in delayed resolution and denial of patient rights. Findings include:

On 10/03/18 at 0910, Pt #2's record was reviewed and revealed the following documents:

A recipient rights complaint form dated 03/13/18 written by recipient rights staff (Staff C). This handwritten form identified the concerns voiced by a community caseworker (the grievant) on behalf of Patient (Pt) #2. This form also contained handwritten contact information and address for the grievant.

An acknowledgment and intervention letter dated 03/28/18 written by Staff C indicating the results of the Office of Recipient Rights (ORR) investigation to the grievant. Note, the address transcribed on this letter was not the same address provided by the grievant on the original recipient rights complaint dated 03/13/18. Also note, the response date was 11 business days from the filing of the original recipient rights complaint.

A letter dated 08/21/18 written by Staff C communicating to the grievant that the complaints filed by the grievant on 03/13/18 had been reassigned for investigation. This letter indicated, "Under most circumstances, the investigation will be completed within 90 days". This letter contained the correct address information of the grievant. Note this letter addressed to the grievant was dated over 5 months from the date the grievant filed the original complaints on 03/13/18. Also note, this letter did not reveal any evidence that a mutually agreeable timeframe for response was made with the grievant.

During an interview with recipient rights staff (Staff C) on 10/03/18 at 0845, Staff C said they received a complaint via phone on 03/13/18 by a caseworker in the community (the grievant) on behalf of Pt #2. Staff C said the grievances were related to medication issues and the failure to provide a safe environment in response to Pt #2's sexual acting-out. Staff C said they wrote down the grievance information by hand on the recipient rights complaint form, informed Pt #2's legal guardian of the concerns and the Office of Recipient Rights (ORR) immediately began an investigation. Staff C said, upon conclusion of the investigation, all grievance allegations voiced by the grievant were not able to be substantiated and the ORR mailed an acknowledgment and intervention letter to the grievant on 03/28/18 informing them of the results. Staff C said as of 03/28/18 the ORR considered the case closed, however on 08/09/18, during an audit by a third-party agency, the ORR became aware of an allegation that the ORR had never sent a response to the grievant who filed the original grievance on 03/13/18. Staff C said the ORR began investigating this allegation between 08/09/18 and 08/21/18 and found, after reviewing the original complaint, that the grievant's address information on the original complaint form (handwritten by Staff C) was transcribed incorrectly. Staff C said the response letter sent on 03/18/18 to the grievant most likely did not reach the grievant at the intended address. Staff C said, after further review, the ORR reopened and reassigned the case and sent a new acknowledgement letter with the correct address to the grievant on 08/21/18. Staff C acknowledged the reason for reopening and reassigning the case should have been made clearer in the letter dated 08/21/18 to the grievant.

On 10/03/18 at 1145 a review of facility policy titled, "Complaint & Grievance Procedures Recipient Rights" last revised September 2015 was completed. This policy indicated, under section B, "2. It is expected that complaints be handled effectively by staff present.", and "6. A written response will be provided within 7 business days to the patient who is the subject of the grievance ...", and "7. If the grievance will not be resolved, or if the investigation will not be completed within 7 business days, (the facility) will inform the grievant and follow up with a response within a mutually agreeable timeframe".