HospitalInspections.org

Based on record review and interview, the facility failed to ensure the provision of a response to a grievance, in that 1 of 1 patients (Patient #1) did not receive a response to a grievance within the specific time frames.

Findings Include:

Daily Nursing Assessment completed on 01/26/2025 at 7:25 PM by Personnel #8, reflected the following, "During shift change, while RN was getting report, this pt [patient]/[Patient #1] reported that his roommate touched him inappropriately on his buttocks. He said 'he was slappy my butt and I told him to stop.' He decided to report because the roommate would not stop. Roommate did not offer any explanation, he just shrugged his shoulders when he was asked...House Sup [supervisor] aware and his mother notified..."

Progress Note completed on 01/27/2025 at 3:19 PM by Personnel #7, reflected the following, "T [therapist] contacted pt [patient] foster mother...for flash update. Foster mother was upset ...felt nothing was being done about pt being touched inappropriately. T stated that the situation is being looked at."

During an interview with the complainant/patient's mother, via telephone on 03/05/2025 at 9:44 AM stated the following, "the incident occurred the end of January. We don't know any of the specifics because [Patient #1] refuses to talk about it. The only thing we know is that it was his roommate and they removed him from the room. I told the facility that I would be reporting the incident to the state. I also contacted the police department. The police told us they couldn't do anything because [Patient #1] wouldn't talk about what happened. I spoke with the nurse advocate and she said she would investigate it and get back to me and she never did. I even went up to the facility to speak with the house supervisor and she told me she would get to the bottom of it, and I never heard anything from her either. I never received any follow up from the facility after multiple requests..."

During an interview with Personnel #1 on 03/05/2025 at 10:30 AM stated the following, "our current Patient Advocate is new and wasn't here when [Patient #1] was here the end of January. [Patient #1] does not show up on our Complaint/Grievance Log for January. We do not have record that [Patient]'s mom filed a grievance with us or that an outcome letter was sent to her. I never spoke with [Patient]'s mom. I will send out an outcome letter to [Patient]'s mom as soon as possible regarding the incident."

During an interview with Personnel #7 via telephone on 03/06/2025 at 3:00 PM stated the following, "I remember [Patient #1] and speaking with his mom regarding an incident with his roommate. I had called the mother to touch base with her and she started asking me questions about what had happened the previous night. I told her I was not aware, but that I would get someone to follow up with her...I apologized to her and told her I would speak with [Patient #1]'s nurse. I updated [Patient #1]'s nurse on what happened, but I did not report the incident to the Patient Advocate. I don't know what happened after that. I had no further contact with the patient's mother."

The Complaint and Grievance Log for January 2025 did not evidence a grievance filed by Patient #1's mother.

The facility policy on "Patient Complaint and Grievance Process" last revised on 04/22/2021 reflected the following, " ...Procedure ...All grievances are to be submitted verbally or in writing to the Patient Advocate, either by the patient, the patient's representative or a staff member to whom the grievance was reported ...The Patient Advocate will conduct an investigation of the grievance, reviewing the patient's medical record, to obtain information regarding the patient's clinical condition ...All grievances receive immediate priority and must be investigated with efforts made toward resolution. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance ..."