HospitalInspections.org

Based on policy review, document review and staff interview, it was determined that for 1 of 6 files reviewed with a grievance (Patient #5), the hospital failed to provide written notice of the results of the grievance decision to the complainant. Findings included:

The hospital policy entitled "Grievance, Patient" stated, " ...A patient grievance ... is a formal or informal written or verbal complaint that is made to the hospital/staff by a patient, or the patient's representative, regarding the patient's care...The Patient Advocate or CEO/designee will review the grievance and...Establish a date by which time a response is expected. If grievances are not resolved with seven (7) days the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution ..."

A. Review of Patient #5's grievance documentation on 12/3/21 revealed the following:
- the hospital was in receipt of a written complaint email dated 11/23/21 at 9:43 AM from the patient's representative (Complainant #1) to CEO A
- complainant #1 expressed concerns related to patient's whereabouts during a transport to a local hospital and missing patient clothing
- written response to Complainant #1 by CEO on 11/23/21 at 3:26 PM stated, "Thank you for this responsive notice. I am familiar with this case and was in conference with CCHS on Friday when these occurrences took place. However, we are investigating the details specifically surrounding her discharge. I will have more information by tomorrow."

No evidence of any other correspondence with Complainant #1 after 11/23/21 as of 12/6/21.

This finding was confirmed by CEO A on 12/6/21 at 1:21 PM.

Based on medical record review, document review, and staff interview it was determined that for 1 out of 6 patients sampled (Patient 2), the agency did not document the patient's advance directive status. Findings include:

Agency Policy "Advance Directive" states: "Admission staff will complete the Advance Directive and Organ Donation Form to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulating an Advance Directive."

Medical record review revealed:
The Advance Directives and Organ Donation form was not completely filled out or signed by Patient 2. The form was signed and dated by the admissions specialist at the time of admission (11/18/2021, 9:00pm).

Interview with Interim DON A at 1:45PM on 12/03/2021 confirmed these findings.

Based on facility document review and staff interview it was determined that the facility failed to meet requirements for notification of patients rights policies to patients. Findings include:

Written notice of facility policies regarding the patient's rights to make decisions concerning their medical care, such as the right to formulate advance directives did not include: clarification of differences between institution-wide conscience objections and those that my be raised by individual physicians or other practitioners, identification of the State legal authority permitting such an objection, and documentation of issuance of the written notice of the hospital's advance directive policies to the patient or the patient's representative.

Interview with CEO A at 3:35PM on 12/03/2021 confirmed these findings.