HospitalInspections.org

Based on review of medical records, facility records and interviews, the facility failed to address a patient's written complaint as per the facility's Grievance Policy.

Findings included:

Facility policy "Grievance, Patient" states in part, "The hospital will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. All patients and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by facility or medical staff.

All patient grievances will be investigated and the results of the investigation reported back to the complainant.

A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf or if hospital has taken appropriate and reasonable action and followed the CMS/State required processes."

" A written complaint is always considered a grievance. This includes written complaints from an inpatient, a discharged patient, or a patient's representative regarding the patient care provided, abuse or neglect or the hospital's complaint with CoPs. For the for the purpose of this requirement, and email or fax is considered "written."
#5. The patient advocate will:
" Mail a written report (by certified mail) if the complainant is not the patient or the patient has been discharged."

In an interview with Staff #2, she stated the facility received a written complaint in the mail from patient #3. The complainant letter date 9/17/19 was presented to the surveyor. The information received by the facility included the complaint letter send to the state by the complainant.

Review of the facilities "Grievance Log" revealed the patient's written complaint sent to the facility dated 09/17/19 was not entered in the grievance log. Staff #2 was asked why it wasn't logged and she stated, "because he was no longer a patient here, if the complaint is received after the patient is discharged it is not a grievance."
The facility's investigation was unsubstantiated.
The result of the investigation was not reported back to the complainant.
A copy of a letter addressed to the patient (not certified mail) did not include investigation findings.

The above findings were confirmed by staff #2 the morning of 2/12/2020.

Based on review of records and interviews, the facility failed to ensure that the patient's parent informed/encouraged to participate in the development and review of their child's individualized treatment plan.

Findings included:

Facility Policy Titled Treatment Planning states in part, "Each patient's treatment shall be guided by the Multidisciplinary Treatment Plan (MTP). The treatment plan is the tool used by the physician and multidisciplinary treatment team to implement the physicians ordered services and move the patient toward the expected outcomes and goals.

h) The patient (or guardian) shall be given the opportunity to have input in the development of the Multidisciplinary Treatment Plan. This shall be accomplished by the therapist meeting with the patient and/or family member to review the recommendations of the treatment team. The therapist shall be responsible for obtaining the signature of the patient or guardian to document acknowledgement of the Multidisciplinary Team Plan."

Review of medical record for patient #2 (age 14) Interdisciplinary Treatment Plan Master Sheets dated 11/9/19 and Interdisciplinary Treatment Update dated 11/19/19, revealed no documentation of family participation or whether the family was informed of the above meetings.

Review of Medical record for patient #1 (age 13) Interdisciplinary Treatment Plan Master Sheets dated 11/7/19 and Interdisciplinary Treatment Update dated 11/28/19 revealed no documentation of family participation or whether the family was informed of the above meetings.

The above findings are confirmed by the Director of Clinical Services.

Based on review of records and interview, the facility failed to ensure that the Medication Consent document was completed and the patient's legally authorized representative was provided with information related to the treatment with psychoactive medications received.

Findings included:

Facility policy, "Informed Consent, Medications revealed the following:
"All patients who have psychotropic medication ordered and legal representatives of patients who have psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication."

Review of the medical record for Patient #1 revealed Medication Consent for the following psychoactive medications: Latuda, Trileptal, Depakote, Zyprexa and Vistaril prescribed between 11/3/19 to 11/30/19 were incomplete. No documentation was observed whether the patient's parent was informed of the benefits and risks of the listed medications.

Patient #2 medical record revealed Medication Consent for Zoloft was obtained on 11/20/19. No documentation was observed whether the patient's parent was informed of the benefits and risks.

The above findings were confirmed by the CNO on the afternoon of 02/11/20.