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NORTHERN LIGHT EASTERN MAINE MEDICAL CENTER
PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION
Tag No.: A0123
Based on document reviews and interviews, the hospital failed to provide a written notice of its determination regarding a grievance in accordance with their policy for one (1) of five (5) sampled patients who filed grievances (Patient #4G).
Finding:
The hospital "Patient Grievance Resolution Process" policy and procedure, last revised 04/05/2018, states in part, "...for those grievances requiring intensive review, an additional 30 business days may be necessary."
On 3/10/2022, the hospital received a grievance from Patient #4G. A written response was provided to the patient on 3/10/2022 and stated, "We are looking into your complaints, and you will receive a full response from us in the mail once a full review has been completed." As of 07/27/2022, there is no evidence of written notice of determination within thirty (30) days of receipt of the grievance.
On 7/27/2022 at 1:40 PM, the Accreditation and Licensing Compliance Officer confirmed a response regarding the full review for grievance #4G has not been provided.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0166
Based on document reviews and interviews, the hospital failed to modify the plan of care to reflect the use of restraints for one (1) of five (5) records. (#5R)
Finding:
The hospital "Restraint and Seclusion" Policy last revised 10/28/2021, states in part: "...Documentation will include but is not limited to...Modifications in the plan of care..."
On 3/20/2022 at 11:20 AM, during documentation review for Patient #5R, the plan of care was not modified to indicate the use of restraints.
On 7/29/2022 at 11:20 AM, the Accreditation and Licensing Compliance Officer, confirmed the documentation for Patient #5R did not include a modification to the plan of care to include the use of restraints.