HospitalInspections.org

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Based on record reviews, staff interviews and review of policy and procedures the Acute Care Hospital failed to follow their policy to resolve patient grievances/concern for 3 of 4 patients ( Patient's 1, 11 and 12). This had the potential to affect all grievances filed with the facility. Facility census was

Findings are:

A. A review of grievances and reported concerns revealed the facility received a concern/grievance from the guardian of Patient 1 on 8/10/18 related to a concern that Patient 1 had been "sexually assaulted" while a patient by another patient at the facility. A review of the process to resolve this concern/grievance lacked a thorough investigation of the incident.

An interview on 9/19/18 at 9:45 AM, the Director of the Behavioral Services Unit (BSU) stated, "because local law enforcement was involved we do not reach out to the patients involved." We did talk to some of the staff that were working and reviewed documentation when this allegedly occurred, but did not talk to either patient or guardians.

Review of a report dated 8/10/18 from the Director of the BSU, lacked a chronological evidence based investigation related to the allegation of sexual assault.

A telephone interview with the local law enforcement investigator on 9/21/18 at 11:30 AM, revealed that the investigator's visited with both patients involved. The patient's both informed the investigators that they were willing participants in any oral sexual activity that occurred between them.


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B. A review of of the grievance log revealed the facility received a grievance from Patient 11 on 8/16/18 related to a concern about care received for hyponatremia, hypokalemia and hyperglycemia, (low blood sodium, critical low blood potassium and very high blood sugar) in the Emergency department (ED) on 8/7/18. The patient stated was transported by ambulance and hospitalized in another town for respiratory failure and kidney failure by primary care physician for 4 1/2 days the very next morning after discharge from Emergency Department on 8/8/18 after 1:30am. A review of the grievance follow up and final letter sent to Patient 11 on 8/22/18 by the Safety/Risk Management Director lacked a thorough documentation of the incident follow up regarding medical care delivered. Documentation in the online reporting system stated "Medical Director of ED reviewed record and visited with staff."

C. A review of the grievance log revealed the facility received a grievance from the parent of Patient 12 ( a minor) on 9/7/18 related to care received in the Emergency Department on 8/27/18 and 8/31/18 for symptoms of weakness and numbness. The patient was diagnosed on 8/31/18 with a stroke and flown to a Children's Hospital for further treatment. Review of the letter sent to the parents of Patient 12 on 9/14/18 stated "I have contacted the Stroke coordinator who reviewed medical record and have asked Neurologist and Emergency Room Medical Director to review medical record as well". No other reports were available in the facility online tracking system.

An interview with Safety/Risk Director on 9/18/18 at 4:38pm revealed that the grievance process investigations for patients 11 and 12 were considered 'completed' as noted in the online statements under heading "Is final resolution": documenting "YES" for both patients.


D. Facility Grievance Policy ADM 16.50, v.2 states under C. 6. Patient Grievance Management: state:
a: "Depending on the nature of the complaint ....Director of the involved Department or appropriate medical staff leadership will be involved."
g: "A grievance is considered resolved when patient is satisfied with the action OR if the hospital has taken appropriate and reasonable action."
h: "In all cases the risk Management department will maintain a file of all written responses" and
i. "All Grievances will be logged into the online event reporting system".

The facility was not following their own policy for the above identified concerns regarding Patient Grievance Management.