HospitalInspections.org

Based on review of clinical records, policies and procedures, hospital documentation, and staff interview, it was determined the hospital failed to follow their policies and procedures for documenting and responding to a family who reported a concern regarding an incident that occurred during Patient #2 hospitalization. This deficient practice poses the risk of patient/family grievances not addressed and potential problems identified and corrected.

Findings include:

The hospital's policy and procedure "Grievance-Patient" included the following: "...All patients and their families...are to 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 Acadia Healthcare staff or physicians...A 'patient grievance'...is a formal or informal written or verbal complaint that is made to the organization by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present)...If the staff member who receives the verbal complaint is unable to resolve the complaint promptly, the staff member should notify his/her supervisor...If the supervisor is unable to resolve the complaint promptly or if the complaint is postponed for later resolution or is referred to other staff for later resolution, requires investigation or further actions for resolution...the complaint is considered a grievance and the supervisor takes the following action...Records the complainant's name; patient name...Advises the person making the complaint that the Patient Advocate/designee will contact him/her as soon as possible...Gives the complainant the name and phone number of the Patient Advocate...When grievances are received, the Patient Advocate will review, investigate and resolve grievances and determine the appropriate response to the complaint. If the grievance involves a confidentiality or privacy concern, it is referred to the Risk Manager....The Patient Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven (7) calendar days,t he Patient Advocate will inform the patient or his/her representative that the organization is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance...The Patient Advocate maintains a record of all complaints and grievances received, including issues addressed, and reports to the Risk Management on a monthly basis, the Quality Committee on a quarterly basis then on to the Governing Board on a quarterly basis. Trends should be identified and addressed as indicated...."

Patient #2 was an adolescent patient who was admitted on 02/11/2020 through 02/19/2020. There was no documentation in the clinical record that reflected an incident involving Patient #3 during the hospitalization.

Patient #3 was also an adolescent patient who was admitted on 02/03/2020 through 02/21/2020. Nursing documentation dated 02/18/2020 at 10:30 p.m. included: "Patient was witnessed going into a peer's room at light-outs. Patient was found lying on the floor between the peer's bed and the wall. Patient was redirected back to her room. Patient stated she knew she was seen and knew she would get into trouble. Patient disclosed she was hoping if she acted up she would not be discharged." There were no other similar incidents documented in the record.

Staff #2 stated during an interview on 07/16/2020 that there was no documentation of an incident or grievance involving Patient #2 and/or Patient #3. Staff #2 reported she spoke with the Director of Human Resources during the complaint investigation survey who had handwritten notes dated 04/08/2020 of interviews of three employees conducted by the Director of Human Resources and the Director of Risk Management at that time. The staff interview notes included documentation that the Director of Risk Management was aware that there were concerns voiced by family member(s). Staff #2 acknowledged the hospital's policies and procedures were not followed for documenting complaints/grievances.