HospitalInspections.org

Based on record review, observation, and interview, the facility failed to inform all patients in the [Name of Unit] the name and telephone numbers for whom to contact to file a grievance. This deficient practice will likely prevent all patients from exercising their right to file a grievance
The findings are:

A. Record review of facility's policy title "Complaints Grievance Policy" "Category: Patient Safety" "Revision Date: 04/13/2023":
"The patient/patient representative shall be informed of whom to contact to file a complaint/grievance. This may be done a variety of mechanisms [sic]: Patient Information Guide; Admission Packet ...."

B. Record review of facility's policy title "Patient Rights" "[Name of Unit] Mental Health Program" "04/16".

"You have the right to be informed of the name and telephone number of the patient advocate. Contact the patient advocate to file a formal complaint any time you think your patient rights have been violated. The patient advocate for [Name of Unit] is either the Unit Director [telephone number] or the Unit Social Worker [telephone number]." (Area code provided by Staff (S)6 Unit Director of Behavioral Health).

C. During an observation on 11/28/2023 at 10:47 am, surveyor called phone number for Unit Director and the call went directly to voicemail without a message greeting. Surveyor called phone number for social worker and the call rang at the nurse station. Call was answered at nurse's station and call was transferred to unknown extension that went directly to voicemail without a message greeting. There was no indication that either phone number was to the patient advocate to file a grievance.

D. During interview on 11/28/2023 at 1:20 pm with Patient (P)11, when asked if someone has gone over the grievance process or explained how the patient can file a complaint, P11 stated "No..."

E. During interview on 11/28/2023 at 1:50 pm with S (Staff) 6 Unit Director of Behavioral Health, S6 confirmed the phone numbers for their office is incorrect. S6 confirmed the phone number for the Unit Social Worker does not have a voice message