HospitalInspections.org

Based on document review and interview the facility failed to resolve grievances that are reported resulting in a lack of follow through on the complaint process for those who file a grievance. Findings include:

On 4/16/15 at approximately 1030 during review of the policy titled, "Non-Discrimination, Patient Rights Protection, and Grievance Resolution" dated "7/12/12" the following is stated: "H. Patient complaints should be addressed by available staff. If the complaint cannot be resolved to the patient's (or the patient's representative's) satisfaction at the time of the complaint, or requires further action for resolution, the complaint formally becomes a 'Patient Grievance' that must be reported to ORR [Office of Recipient Rights] and/or the Hospital Director/Designee."

On 4/16/15 at approximately 1140, during an interview with Staff C, this surveyor asked "If a complaint becomes a grievance, do your staff report it to the hospital designee for investigation and resolution?" Staff C stated, "Only if ORR doesn't resolve it or the patient asks. But, they [the patient] just used the ORR forms, they almost never use the hospital process." This surveyor asked Staff C, "Do you think the patients realize the hospital process is different then the ORR process?" Staff C stated, "We give them the patient rights pamphlet when they are admitted, which discusses that." This surveyor then asked, "A majority of your patients are here for years, do you think they forget that the hospital has a process, or does not understand the hospital process if it is almost never used?" Staff C stated "I don't know, some of them walk around with the pamphlets and know what it says." This surveyor stated, "It seems strange that the patients almost never use the hospital complaint/grievance process."

On 4/16/15 at approximately 1145 during an interview with staff C, this surveyor asked about the resolution of the grievances listed on the grievance log. Staff C stated, "I would have to call the managers to find out what was done with these." This surveyor asked, "If you are the responsible person who manages all the complaints, and you do not know if they are resolved how are you tracking the status of these?" Staff C stated, "Well if I do not hear back from the patient I assume they are not having the same problem. If I hear back from them, then I follow up." This surveyor asked if staff C discusses the allegations with the complainants. Staff C responded, "There is no way I have time to talk to every complainant."

Based on document review and interview the facility failed to follow up on grievances in a timely manner, resulting in the potential for unresolved grievances and/or ongoing harm. Findings include:

On 4/16/15 at approximately 1030 during review of the policy titled, "Non-Discrimination, Patient Rights Protection, and Grievance Resolution" dated "7/12/12" the following is stated: "Procedures: Risk Manager 10. Responds in writing within 30 days of receipt of any ORR Complaints found "not a code protected right", any patient grievances submitted by staff, or any complaints identified not resolved during government meetings."

On 4/16/15 at approximately 1040 during an interview with staff B, this surveyor asked "30 days is a fairly long time for a response considering your patients are so vulnerable and are here for very long periods most of the time. Does that seem long to you?" Staff B stated, "Yes, especially if we do not hear about the complaint until after ORR has investigated them."