HospitalInspections.org

Based on document review and staff interview, it was determined in 1 of 1 (Pt #10) clinical record reviewed, the hospital failed to ensure the grievance was reviewed, investigated and resolved with in a reasonable time frame. This has the potential to affect all patients/caregivers receiving care by the Hospital.

Findings include:

1. The policy titled "Patient/ Resident Complaint/ Grievance (last revised 08/2023)" was reviewed on 9/27/23. The policy noted "...1. A "patient grievance" is defined as "written or verbal complaint...by a patient or the patient's representative regarding the patient's care...7. Patient complaints that are considered grievances also include situations where a patient or a patient's representatives telephone the hospital with a complaint...13. Response letter shall be forwarded to the patient or patient representatives no later than 7 days after receipt of the grievance..."

2. The clinical record of Pt. #10 was reviewed on 9/27/23. Pt. #10 was admitted 7/26/23 and discharged on 8/2/23 with a Diagnoses of Major Depressive Disorder and Bipolar Disorder. The patient discharge summary report (instructions given to patient upon discharge) noted discharge medications of Elavil 25 mg/ Elavil 50 mg by mouth take 3 tablets at bedtime and Seroquel 50 mg/ Seroquel 100 mg by mouth take 3 tablets at bedtime. The medication profile report to pharmacy ordered by physician noted same medication order as the discharge summary report (to take 3 tablets each at bedtime). The physician discharge summary noted Elavil 75 mg at night and Seroquel 150 mg by mouth at night. There were multiple phone calls and emails from a complainant regarding a complaint of the discrepancies in the medications from discharge. The complaint log was reviewed for the past 3 months and lacked a complaint/ grievance documented and/ or reviewed and lacked letter of response sent.

3. During an interview with the Director Infection Control/ Quality (E#1) on 9/28/23 at approximately 12:00 PM, it was verbally confirmed a complaint/ grievance wasn't filed in the complaint log. Also no letter of response was sent.