HospitalInspections.org

Based on document review and interview with key personnel on March 14, 2012, it was determined that the facility failed to protect patient rights per the Rules for the Licensing of Hospitals 3.2 which states "A critical access hospital must protect patient rights and comply with the conditions for patient rights contained in C.F.R. 482.13..."

The findings include:

1. C.F.R. 482.13(a)(2)(ii) states " The grievance process must specify time frames for review of the grievance and the provision of a response."

2. On March 14, 2012, a review of ADM-302 Policy " Patient Complaint /Grievance" was conducted. Section 7.0 provides specific instructions on how to handle a " complainant who is not satisfied with the final response .... "

3. A review of Patient A's complaint was conducted. The final sentence states, " Pt remains very upset " .

4. During an interview on March 14, 2012, with the Director of Risk Management, she acknowledged that she was the writer of the final entry in Patient A's complaint. She also acknowledged that she failed to inform Patient A of the process outlined in Section 7.0 whereby an Independent Review Panel could be established to review how the original complaint had been investigated. She stated, " No, I didn't tell her how to do this ...I didn't follow my policy. "

5. C.F.R. 482.13(a)(2)(iii) states " In its resolution of the grievance, the hospital must provide the patient with...the name of the hospital contact person, the steps taken on behalf of the patient.... and the date of completion"

6. On March 14, 2012, a review of ADM-302 Policy " Patient Complaint /Grievance " was conducted.

7. The policy failed to state that the hospital would provide a written response to the complainant that included the decision, the name of the hospital contact person, the steps taken on behalf of the complainant, the results of the grievance process, and the completion date.

8. This was confirmed with the Director of Risk Management. She stated " I can see that our policy needs to be tightened up ... "

Based on document review and interview with key personnel on March 14, 2012, it was determined that the governing body failed to ensure that established policies were followed. The findings include:

1. On March 14, 2012, a review of ADM-302 Policy " Patient Complaint /Grievance " was conducted. Section 2.0 states " ...all hospital employees ...share the obligation to receive complaints, attempt immediate resolution and forward appropriately. "
2. A review of the hospital ' s documentation " Unusual Occurrence Report " , regarding Patient A ' s complaint indicated that the complainant was told during two (2) separate telephone calls on November 21, 2011, that she would have to call the hospital administrator regarding her allegations.
3. These findings were confirmed during an interview on March 14, 2012, with the Director of Risk Management. She acknowledged that the complaint was not handled in accordance with the policy.