HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to establish a process for prompt resolution of patient grievances.

Findings include:

Review of the policy entitled "Grievance" reviewed April 2009 revealed, "I. Policy Any patient (or those helping him/her) may initiate a complaint, orally or in writing concerning his/her Interdisciplinary Treatment Plan, the exercise of his/her rights or the quality of services at the facility ... IV. Procedures ... D. The Patient Advocate receiving the complaint shall investigate the complaint and make every effort to resolve it. 1. A decision shall be given in writing as soon as possible, but within forty-eight (48) hours after the filing of the complaint. 2. Complaints are decided by persons not directly involved in the circumstances leading to the grievance. E. The patient shall be given a written copy of the complaint and the final decision. 1. A copy is also filed in the patient's medical record. F. The Clinical Program Administrator/DON shall maintain a formal record of patient complaints and grievances, etc., for review for certification and licensure, etc ..." The policy did not differentiate between the handling of complaints and grievances.

1. Review of MR1 revealed the patient was admitted voluntarily to the facility following an intentional overdose of medication in an attempted suicide that was treated at another facility. The patient arrived at the hospital at approximately 12:10 AM. According to the medical record the patient retained shoelaces and had been able to tie them around the neck tight enough to leave "slight purple/red marks to neck." A nursing note at 3:41 PM the same day revealed that family requested to speak with nursing staff about the patient having contraband that threatened patient safety. Since the medical record was not available, the family were instructed to call back later for information if the appropriate release was signed and in the medical record. The social worker then was contacted to speak with an "irate family." At that point the family was threatening to contact police over their concern that the facility staff neglected to confiscate shoelaces, resulting in potential harm to the patient. The CEO then spoke with the family. The medical record failed to reveal documentation that the patient/family was given a written copy of the complaint or the final decision in compliance with facility policy.

2. Review of complaints/grievances for September 2009-February 2010 revealed one grievance. There was no documentation of a complaint/grievance filed for MR1 although family were clearly upset with the situation. There was no written response to the complaint/family regarding the safety of the patient as required by facility policy.

3. Interview with EMP2 on February 19, 2010, at approximately 11:00 AM revealed, "The incident was investigated." EMP2 further confirmed there was no written response regarding the investigation, "because we thought it was taken care of on the spot."

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to provide patients with a written notice of its decision that contained the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for two of two grievances.

Findings include:

Review of the policy entitled "Grievance" reviewed April 2009 revealed, "I. Policy Any patient (or those helping him/her) may initiate a complaint, orally or in writing concerning his/her Interdisciplinary Treatment Plan, the exercise of his/her rights or the quality of services at the facility ... IV. Procedures ... D. The Patient Advocate receiving the complaint shall investigate the complaint and make every effort to resolve it. 1. A decision shall be given in writing as soon as possible, but within forty-eight (48) hours after the filing of the complaint. 2. Complaints are decided by persons not directly involved in the circumstances leading to the grievance. E. The patient shall be given a written copy of the complaint and the final decision. 1. A copy is also filed in the patient's medical record. F. The Clinical Program Administrator/DON shall maintain a formal record of patient complaints and grievances, etc., for review for certification and licensure, etc ..."

1. Review of complaints/grievances for September 2009-February 2010 revealed one grievance. The letter to the complainant indicated, "I am writing in response to our phone conversation ... in which you advised me of several concerns that you had during your most recent stay with us. I just wanted to let you know that I addressed your concerns with the staff." The letter was signed by EMP2. The letter failed to include the steps taken on behalf of the patient, the results of the grievance process, and the date of completion. It also failed to define the difference between complaints and grievances.

2. Interview on February 19, 2010, at approximately 11:00 AM with EMP2 revealed the policy for complaints/grievances was written based on the Pennsylvania Code, Title 55 Public Welfare requirements. EMP2 added, "That is the only policy we have for complaints/grievances. We would be glad to add a policy that would meet the federal requirements."