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Based on observation, interview and record review, the facility failed to establish a process for timely review and resolution of written grievances filed by 2 psychiatric inpatients (#8 and #9), resulting in the potential loss of Centers for Medicare and Medicaid (CMS) grievance rights for all psychiatric inpatients. Findings include:
Policy Review:
On 9/3/14 from 1000-1030 a review of facility policy titled, "Patient/Family Complaint and Grievance Process", dated "4/28/14", stated:
"A written complaint is always considered a grievance."
Observation:
On 9/2/14 at 1345, during a tour of the inpatient psychiatric unit, a wall-mounted box labeled "complaints" was observed. Blank complaint forms were observed beside the box. A wall-mounted posting was observed, listing Patient Rights and providing contact information for patient advocacy agencies, the hospital's Patient Relations Department and the State of Michigan Complaint Hotline. There was no posting indicating that complaints placed in the complaint box would not be reviewed for compliance with CMS Standards or treated as grievances.
Record Review, patient #8:
1. On 9/3/14 at 1000, review of the facility's "Recipient Rights Complaint Log" revealed an open complaint filed by patient #8, received on 8/29/14. The complaint was not listed on the facility's "Grievance Log." Pt. #8 was discharged on 8/29/14.
2. On 9/3/14 at 1000, record review revealed that patient #8's written complaint states that physician G disclosed private information without the patient's permission. The complaint stated that the patient's HIPPA and privacy rights were violated. The complainant stated the desire to pursue suspension of physician G's license.
3. On 9/3/14 at 1010, record review revealed that on 9/2/14 facility staff E sent patient #8 a letter acknowledging the above complaint. The letter stated that the complaint will be reviewed for compliance with Michigan Mental Health Code requirements. The letter did not state that the complaint will be reviewed for compliance with CMS Standards. The letter lists agency contacts for filing complaints. The list does not include information on how to file a complaint against a Michigan physician.
4. On 9/3/14 at 1010, record review revealed that the 9/2/14 letter (above) stated that the complaint is not being assigned for investigation. (The check box stating "Your complaint has been assigned for investigation" was not checked.) The letter stated that the patient could expect a written response within 30 days of the 9/2/14 letter.
Interview:
1. On 9/3/14 at 102,5 staff E stated that: "the complaint box (on the Psychiatric Unit) is checked 2-3 times a week." Staff E stated, that there was no way to know how long patient #8's complaint remained unread in the box. Staff E confirmed that patient #8's complaint was not read until the patient's discharge date, 8/29/14.
2. On 9/3/14 at 1030 staff E confirmed that there is currently no process for reviewing written grievances placed in the inpatient psychiatric unit's complaint box for compliance with CMS Standards.
Record Review, patient #9:
1. On 9/3/14 at 1000, review of the "Recipient Rights Complaint Log" revealed a complaint filed by patient #9, received on 7/14/14. Patient #9 complained of inadequate medication for pain control. Patient #9's complaint was not listed on the facility's Grievance Log. Patient #9 was discharged on 7/16/14.
2. On 9/4/14 at 1015 review of patient #9's clinical record revealed a medical "History & Physical" dated "7/9/14" and listed a diagnoses of "chronic left foot pain" and DJD (Degenerative Joint Disease).
3. On 9/3/14 at approximately 1020, review of the facility's response to patient #9's written complaint revealed a letter from staff I to patient #9, dated 7/14/14, listing the times that the pain relief medications Ultram and Motrin were administered on 7/14/14 and stating: "Thus, based on the preponderance of evidence your allegation is unsubstantiated." No documentation of staff reporting patient #9's complaint of inadequate pain control to the patient's physician in response to this complaint was found. No documentation of a physician response to this complaint was found.
Interviews:
1. On 9/3/14 from 1000-1030, during record review, staff E confirmed the record review findings noted in #1 and #3, above.
2. On 9/4/15 staff F confirmed all findings noted above. Staff F confirmed that facility's "Patient/Family Complaint and Grievance" policy was not followed in responding to this complaint.