HospitalInspections.org

Based on observation, interviews and review of policies and procedures, it was determined that the hospital failed to inform each emergency department (ED) patient of his/her patient rights.

Findings include:

1. A tour of the ED was conducted on 12/06/2012 between 0750-0845 with the Emergency Services Director, I1, Emergency Department Manager, I2, and the Director of Behavioral Health. The tour included 3 ED patient care pods, the ED Behavioral Health 5-bed locked unit, registration/admission office, triage office, security office and ED patient/visitor waiting room.

2. The admission and registration process was observed during the tour. The hospital admission packet was received from an ED registration personnel, I3 on 12/06/2012 at 0815. The packet contained a folded document titled "St. Charles HEALTH SYSTEM Notice of Privacy Practices," dated effective 08/01/2012 and a brochure titled "HEALING HEALTH CARE and PATIENT RIGHTS and RESPONSIBILITIES," dated 12/2008.

I3 was asked if all ED patients/patient representatives received the patient rights brochure when patients were admitted to the ED. I3 initially stated the packet was "only given to patients when they were admitted as inpatients." I3 later clarified that the Patient Rights brochure was given to ED patients if they requested the information.

3. The policy and procedure titled "Patients' Rights and Responsibilities," Policy #Q0915, Revision J, undated, reflected "3. SCOPE: This procedure applies to all patients (inpatients and outpatients) and all caregivers...6. PROCEDURE: Each patient (or representative) will be given a copy of 'Patient Rights and Responsibilities' upon admission, or when discontinuing patient care whenever possible."

The hospital failed to inform each ED patient, or when appropriate, the patient's representative of the patient's rights in advance of furnishing patient care per this regulation.

Based on interview, review of policies and procedures, and other patient admission documents, it was determined that the hospital failed to implement a clearly explained procedure for the submission of and response to patients' grievances. In addition, it did not inform the patient of the right to receive a written response to a complaint/grievance.

Findings include:

1. Review of the hospital's procedure titled "Patient/Patient Representative Complaint/Grievance Resolution Process," effective 03/27/2012 reflected, "Whenever possible, a patient/patient representative complaint shall be immediately resolved by the receiving caregiver. When immediate resolution does not occur, this grievance resolution process will be used for unresolved verbal complaints and all written complaints received from patients...Receiver of complaint: 1. Attempt to resolve the complaint when the complaint is received...Immediately document the unresolved grievance in the Complaint section of the Event Management System (EMS)...Manager or Designee: 1. Investigates the documented grievance within seven days...Responds to the patient/patient representative in writing within seven days of receiving the EMS Management Investigation Task...respond to the complainant using the form letter...The written response must minimally include..."

2. Review of the document titled, "HEALING HEALTH CARE and PATIENT RIGHTS and RESPONSIBILITIES," dated 12/2006, provided to patients upon admission to the hospital, reflected "Patient and Parent Rights...You have a right to:...23. To voice complaints and suggest changes in service or staff without fear of reprisal or discrimination. If you have a concern or complaint, ask to speak to a supervisor or nurse in charge. Register a complaint with St. Charles Medical Center - Bend Administration at...If you are not satisfied with the resolution of an issue, you have the right to make an appeal to the Chief Executive Officer."

3. An interview was conducted with the hospital's Clinical Risk Manager, I4, on 12/06/2012 at 0930. The manager confirmed "I don't believe patients receive any information regarding how to file a grievance or any of the timelines that we have included in our own policy."

4. The grievance process information provided to patients contained unclear information related to the submission of complaints about any aspect of care or treatment. Patients received no information regarding verbal versus a written grievance or timelines for a written response to a grievance as reflected in the hospital's "Patient/Patient Representative Complaint/Grievance Resolution Process" procedure referred to above.