HospitalInspections.org

Based on review of hospital policy, review of grievance files and staff interview, the hospital failed to provide written notice of the resolution of a grievance in 3 of 3 grievances reviewed (Pt #8, 9 and 1 ).

The findings include:

Review of the hospital's policy, "Patient Grievance Procedure", revised 01/20/2009, revealed, "POLICY: It is the policy of (name of facility) to ensure reasonable expectations of patient care and services and to address those expectations in a timely, reasonable, and consistent manner. In the event that any patient or patient's representative does not feel that reasonable expectations of patient care and services are being met, the patient or the patient's representative has the right to lodge a grievance, verbally or in writing. DEFINITION: A 'patient grievance' is a formal or informal verbal or written complaint that is made to the facility by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. If a complaint cannot be resolved promptly by staff present, it is considered a grievance. Patient grievances also include situations where patients or the patient's representative call or write the facility about a concern(s) related to care or services and were unable to resolve their concern during their stay or who did not wish to address their issue during their stay. PROCEDURE: ...3. ...The Director of Counseling shall respond to the grievance, in writing, within 2 business days and no later than 7 days. Written notification will include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of completion, and a contact person. ...".

1. Grievance file review on 05/23/2012 for Patient #8 revealed the patient's representative called the facility 11/08/2011 regarding medical records request made at the time of the patient's discharge on 10/21/2011. File review revealed no written notification has been sent regarding the grievance that was called to the facility on 11/08/2011 (6 months, 15 days ago).

Interview on 05/23/2012 at 1030 with Administrative Staff confirmed no written notification of the grievance resolution was sent to Patient #8's representative. Interview further revealed, "no letters have been sent for any of the grievances". Interview confirmed the hospital's grievance policy was not followed.

2. Grievance file review on 05/23/2012 for Patient #9 revealed the patient's husband called the facility on 05/03/2012 regarding care concerns for the patient. File review revealed no written notification has been sent regarding the grievance that was called to the facility on 05/03/2012 (20 days later).

Interview on 05/23/2012 at 1030 with Administrative Staff confirmed no written notification of the grievance resolution was sent to Patient #9's representative. Interview further revealed, "no letters have been sent for any of the grievances". Interview confirmed the hospital's grievance policy was not followed.

3. Closed record review of Patient #1 revealed a 37 year old male, admitted 01/17/2012 for opiate detoxification. Record review revealed the patient was discharged on 01/25/2012. Record review showed an "Integrated Progress Note" dated Saturday, 1/21/2012 at 6:58 PM completed by the weekend counselor, "pt had entered treatment on the 17th and had not met his counselor, did not know who his counselor is, did not know where his counselor's office is, had not been given information about many issues and had often been given conflicting information from various staff members." Per the patient complaint he was attempting to receive 1:1 counseling sessions with his counselor.

Interview on 5/23/2012 at 10:20 am with the weekend counselor revealed she had e-mailed the patient's co-counselor about this patient's complaints. Interview with the co-counselor on 5/23/2012 at 12:25 PM revealed she could not recall this patient or having been informed about his issues. Interview on 5/23/2012 at 10:45 AM with the Lead counselor for this patient revealed he had spoken with the patient and he had indicated to the counselor he was not happy with his treatment. The Lead counselor also indicated he had not documented any of this.

Further review of the patient's medical record revealed no documentation that the patient's complaint had been investigated or any resolution to his concerns was provided.

Interview with the DON and the Director of Counseling on 5/23/2012 at 2:30 PM revealed that this incident had not been treated as a grievance and the facility failed to follow the grievance policy.

The facility failed to ensure, with the patient's input, an appropriate plan of care that met the patient's needs for 1 of 4 record reviews. (#1).

Findings include:

An undated "Clinical Services Master Treatment Plan" Policy states "Charting" ...3. The Primary Counselor will then review the Master Treatment Plan with the patient for his/her input. Patient will sign Master Treatment Plan indicating it has been reviewed by patient and primary counselor and that patient has been actively involved in identifying problems and setting goals." An undated Addendum: states, "All treatment planning involves the patient. The patient is interviewed during the completion of the Clinical Formulation and this interview process is utilized for patient and clinician to work together to develop the individualized treatment plans."...

Review of closed medical record for patient #1 revealed a 37 year old male admitted on 01/17/2012 for opiate detoxification and was discharged 01/25/2012. Record review revealed an "Integrated Progress Note" dated Saturday, 1/21/2012 at 1858 completed by the weekend counselor. She documented that "the pt's girlfriend reported that pt had entered treatment on the 17th and had not met his counselor, did not know who his counselor is, did not know where his counselor's office is, had not been given information about many issues and had often been given conflicting information from various staff members. Further review revealed, "When the pt's primary counselor called me, he said 'I think we're off to a good start' and I assumed he meant he had met individually with the pt". Documentation further revealed, "the counselor gave Patient #1's girlfriend information that patients sign up for 1:1 sessions and rationale for the preponderance of group therapy for chemically dependent persons. One of her primary concerns was that pt's FMLA paperwork get to the appropriate personnel then forwarded to pt's employer. The counselor said she would notify the Lead Counselor of all concerns, send an e-mail to pt's primary counselor (reminding her that he works Tuesday through Saturday), meet herself with pt in the morning and keep her updated on pt's status. The girlfriend was given the direct line phone numbers for the counselor, for Lead Counselor on weekends, for pt's primary counselor and for primary's co-counselor. "

Further review revealed, on 1/22/2012 at 8:03 AM another "Integrated Progress Note" was written by the same weekend counselor. It stated "Writer sought out pt. and found him sitting at a table in the lobby of the Clinical Building. Introduced self to pt. and offered to discuss his concerns, to show him the office location of both his primary counselor and his co-counselor and to let him know the formal procedure for scheduling specific individual sessions. As it happens, pt had signed up on the 19th to meet with his primary on the 20th and said he had showed up on time then waited outside his office for a long time...but since he was dealing with some kind of emergency situation and was obviously going to be held up for quite some time, I just handed him my completed portion of my FMLA forms and asked that he get them to the correct personnel. Pt verbalized frustrations with receiving different directions from different staff about the same thing...and some of what staff says doesn't match what's in the Patient Handbook. Pt thanked writer for seeking him out and clarifying some issues but said he "probably won't be staying...there are patients here who aren't serious about recovery and I want an environment without that kind of distractions." Writer urged pt. to remain in treatment and let him know the Lead Counselor would be meeting with him later this morning. Reported above discussion to Lead Counselor."

Further review revealed, on 1/22/2012 at 6:10 PM another "Integrated Progress Note" was written again by the same weekend counselor. It stated "Contacted pt's concerned other to update her on day's events. Patient's concerned other said she knew writer and Lead Counselor had met with pt today and addressed many of his concerns buy that "we put in our 72 hour notice today." She reported having researched other possible inpatient treatment facilities that would be a better fit for them, assuring writer that pt truly wanted treatment-just not at (name of facility). She said she'd been reading information on CRC web site and that pt would be wanting a copy of his medical records, that he would be submitting his request in writing tomorrow and would give the written request to his co-counselor. The concerned other thanked writer for her availability and for ensuring she (the concerned other) remained informed.
Writer notified the co-counselor via e-mail that pt may be submitting written request in the morning for his medical records"

Review of the closed medial record for patient #1 revealed no 1:1 sessions with the patient and the Lead counselor or the co-counselor. The patient attended group therapy sessions only.

Interview on 5/23/2012 at 10:20 am, with the weekend counselor revealed she had e-mailed the patient's co-counselor about this patient's complaints. Interview with the co-counselor on 5/23/2012 at 12:25 PM revealed she could not recall this patient or having been informed about his issues. Interview on 5/23/2012 at 10:45 AM with the Lead counselor for this patient revealed he had spoken with the patient and the pt had indicated to the counselor he was not happy with his treatment. Review of the medical record showed no Plan of Treatment had been formulated with the patient's participation. The Lead counselor also indicated he had not documented any of his conversations with the patient regarding the patient's displeasure with his treatment.

Interview with the Director of Counseling on 5/23/2012 at 3:00 PM revealed a Plan of Treatment with the patient's input should have been completed and placed in the patient's medical record and the requested 1:1 sessions with the counselor should have been provided. Interview revealed the facility's policy for treatment planning with patient input was not followed.

Review of the hospital's policies, pharmacy services agreement, pharmacist inspection reports, pharmacy and therapeutic committee meeting minutes and staff interview, the hospital's pharmacist failed to develop, supervise and coordinate the monitoring of the pharmaceutical services of the hospital.

The findings include:

Review of the hospital's policy, "Pharmaceutical Plan", revised 04/2011, revealed, " Policy: It is the policy of (name of facility) that pharmaceutical services will be provided to the (name of facility) through a private pharmacy service. A pharmacist...will provide consulting services. Procedure: 1. Pharmacy Services will ensure compliance with all legal requirements...2. The following outline of the various functions of the pharmacy will serve to comply with applicable state laws...E. The Pharmacist inspects all pharmaceutical areas on a monthly basis. A record of these inspections is maintained. ...3. The Consultant Pharmacist will supervise the storage and distribution of all medications used in the facility. ...A. The Consultant Pharmacist conducts monthly inspections of drug storage units and submits these reports to the facility in written form. ...".

Review of the hospital's policy, "Pharmacy & Therapeutics Committee", revised 04/2011, revealed, "Policy: It is the policy of (name of facility) that a program be in place to assure safe storage, preparation, distribution and administration of drugs to reduce potential hazards for patients. The Leadership/Management Committee and the Pharmacy Consultant shall assume responsibility for this function. Procedure: Members of the Leadership/Management Committee, including but not limited to the Medical Director, Director of Nursing, Performance Improvement Coordinator, in association with the Pharmacy Consultant shall participate in and serve the function of Pharmacy Review Committee. This body will meet at least quarterly, with more frequent meetings as necessary. Minutes of the meeting shall be contained within the body of the minutes of the Quarterly Leadership/Management Committee meeting. ...".

Review of the Pharmacy Services Agreement, dated and signed by the general manager of the pharmacy company and the hospital's executive director on 11/30/2006, revealed Schedule A-3, "Consulting Services and Pricing". Review of Schedule A-3 of the pharmacy agreement revealed, "...e. Once each quarter, observe a medication pass from the Facility to a patient, and note concerns related to quality assurance (if any) to the Facility's administrator. ...h. Once each quarter, attend a meeting with the Administrator and Director of Nursing at each Facility to discuss pharmacy issues. ...".

Review of the pharmacist inspection reports revealed the last documented pharmacist inspection was conducted 01/12/2012 (4 months, 11 days ago). Review revealed the previous pharmacist inspection was conducted 06/10/2011 (6 months prior to the 01/12/2012 inspection).

Review of the Pharmacy and Therapeutic Committee Meeting minutes revealed the last meeting was held 11/09/2010 (1 year, 6 months ago).

Interview on 05/22/2012 at 1300 with the Director of Nursing revealed, "we have not had a P&T (Pharmacy and Therapeutics) committee meeting for several months. Our contract pharmacist visits about every two to three months".

Interview on 05/23/2012 at 1045 via telephone with the contracted Director of Pharmacy revealed, "I don't remember when the last P&T committee was held". Further interview revealed, "we do not inspect the pharmacy areas monthly. We attempt to inspect quarterly". Further interview revealed, "I have scribbled notes from a meeting we had October 21, 2011 and November 8, 2011. There is no documentation of meeting minutes". Interview further revealed the contract with the hospital did not provide certain time frames for inspections and meetings.