HospitalInspections.org

Based on document review, interview and observation, the facility failed to inform patients of their rights. Findings include:

During an interview with the Quality & Risk Manager on 01/11/2012 at 1600, a request was made for the admission paper work utilized for a patient. A review of the documentation provided lacked evidence of patient's being informed of their rights at the time of admission.
The lack of patient's rights was confirmed by the Quality & Risk Manager. When queried about this again, he stated "this was all they gave me."

During a tour and observation of the medical surgical/pediatric unit on 01/12/2012, it revealed that the "patient bill of rights" for Dickinson County Healthcare System was posted on the wall across from the nurse's station it stated "The right to voice concerns/complaints through the Department Manager, Patient Advocate or Hospital Administrator. The right to a rigorous system of internal review and an independent system of external review." It lacked information informing the patient of whom to contact if they choose to have an external review.

During an interview with the Assistant Manager of Med/Surg/Peds/ICU/IMC on 01/11/2012 at 1300, she stated that all the patient rooms have the "Patient Guide" that contains information on how to file a complaint or grievance with an outside agency. Review of the guide revealed a document titled Care Plan and it reveals the following under the section titled Michigan Department of Community Health: Bureau of Health Systems "The Michigan Department of Community Health (MDCH) has outlined a citizen's guide to filing a complaint... Anyone may file a complaint by: Submitting the online complaint form on the internet at http://www.michigan.gov/bhs or completing and mailing a health facility complaint form (BHS-OPS-361)."
During an interview on the unit with the Health Unit Coordinator at 1330, this surveyor requested to see a copy of the citizen's guide to filing a complaint. The Health Unit Coordinator was unaware of this booklet. The Assistant manager of the unit who was also present at the time of the request was also unable to produce the booklet.

Based on record review and interview, the hospital's governing body failed to ensure that hospital staff follow the grievance process requirements. Findings include:

During review of six (6) written grievances that involved patient care issues there was no documentation of the six complainants receiving a written resolution letter.

During an interview with the Patient Advocate on 01/12/2012 at 1030, she confirmed the findings and stated ' I have not sent out letters to anyone, I usually just speak to them on the phone."

These findings were also discussed with the hospital President and the Quality & Risk Manager at the time of the exit conference.

Based on record review and interview the facility failed to provide resolution letters to patient's that had filed a written grievance with the hospital. Findings include:

During a review of written grievances that the hospital's Patient Advocate had received during the past year (2011), it was determined that (6 of 6) lacked documentation of a resolution letter that should have been sent to the patient.

During an interview with the Patient Advocate on 01/12/2012 at 1030, she confirmed the findings and stated ' I have not sent out letters to anyone."