HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1(Pt #1) reviewed for grievance of harassment, the hospital failed to ensure an investigation was conducted and the grievance resolution was documented.

Findings include:

1. The Hospital policy titled "Patient Complaint/Grievance Resolution Process and Feedback Program" (reviewed 6/22/12), was reviewed on 11/20/13, required, " Grievance Process: A grievance process is a. Any written (e.g. letter, note, fax, email) or verbal complaint regarding patient's care that cannot be resolved in a timely and reasonable manner including but not limited to... b. Any concern related to alleged abuse and neglect. c. Any concern related to alleged patient harm or danger...Following completion of the investigation within the stated number of days... sends a written response to the patient or patient representative which includes, at a minimum: written notice of its decision, ...steps taken on behalf of the patient to investigate grievance; the result of the grievance process; and date of completion."

2. The complaint and grievance log was reviewed from 5/1/13 to 11/19/13. The log contained 3 complaints and 2 grievances, with documentation of responses to the grievance within the stated number of days of acknowledgement. However, the log did not include the complaint from Pt. #1 of harassment and bullying by several male adolescent patients.

3. The clinical record for Pt. #1 was reviewed on 1/19/13. Pt. #1 was a 22 year old female, admitted on 10/13/13. Pt. #1 was a 22 year old female, admitted on 10/3/13 with a chief complaint of " unable to walk." Pt. #1's clinical record included documentation by a Psychologist (E #6) on 11/6/13, indicating an incident occurring with other patients. Documentation included: "Pt recounted the experiences in which pt was exposed to bullying and harassment by several adolescent male patients. Pt discussed the emotions connected to this experience, including a sense that she was ' raped ' and feeling unsafe." There was no other documentation of Pt. #1's complaint by nursing staff, therapists or physician.

4. On 11/19/13 at approximately 9:15 AM the Unit Manager (E# 2) of the Pediatric Unit was interviewed. E #2 stated, " There was an occurrence that occurred with the patient and 4 male patients. The patient felt threatened by the boys. The harassment occurred only one night." E #2 stated that she was aware of the complaint and incidence of bullying and spoke with the patients involved however a complaint/grievance was not documented.

5. The above findings were discussed with the Unit Manger and the Director of Quality Improvement during an interview on 11/21/13 at approximately 12:30 AM and stated that the complaint was not documented.

Based on document review, and interview, it was determined for 1 of 1 clinical record reviewed (Pt. #1) for grievance of harassment, the hospital failed to investigate the incidence and complaint of harassment.

Findings include:

1. The Hospital policy titled "Unusual Occurrence Documentation" (revised 6/17/13), reviewed on 11/19/13, required, "All unusual occurrences regardless of severity or potential consequences are documented. An unusual occurrence is any unexpected event which... reflects a variation from customary policy/procedure or practice affecting patient care... All unusual occurrences involving inpatients...are reported on the Unusual Occurrence Form."

2. The Log of incidences for 8/1/13 to 9/19/13 was reviewed on 9/19/13 at approximately 11:10 AM. There were no incidences documented relative to Pt. #1 or any harassment issues.

3. Interviews with The Director or Quality Improvement and Accreditation were conducted on 11/19/13 at approximately 10:30 AM and 11:10 AM. The Director stated there were no incidences reported relative to Pt. #1.

4. An interview with the Unit Manager of 5 (E #2), was conducted on 11/21/13 at approximately 12:30 PM. E #2 stated that she was aware of the complaint and incidence of bullying and spoke with the staff involved however an incident report was not completed nor was the investigation and actions taken documented.

5. The above findings were discussed with the Unit Manger and the Director of Quality Improvement during the interview on 11/21/13 at approximately 12:30 PM, who stated that an incident report was not completed.