HospitalInspections.org

Based on document review and staff interview, the facility did not establish policies and procedures to ensure timely resolution of grievances. As a result, grievances were not resolved timely in 4 of 12 grievances reviewed.

Findings include:


Review of Complaint/Grievance log on 1/6/16 noted that Grievance #1 was filed on 10/18/15 and was acknowledged by the facility; however, the investigation is ongoing and has not been resolved.

Grievance #2 was filed on 10/27/15 regarding inadequate nursing care. There was no acknowledgement letter to the complainant and no investigation of the grievance as at 1/6/16.

Grievance #3 was filed on 11/5/15 related to inadequate care at the facility. The investigation was completed on 12/21/15; however, there was no indication that a letter had been sent to the complainant regarding the outcome of the investigation.

Grievance #4 was filed on 12/3/15 regarding inadequate care and was resolved on 12/30/14. The resolution of this grievance was completed twenty-seven days after receipt of the grievance.

The facility policy and procedure titled "Complaint and Compliment Policy" revised July 2014, contains the following: "The Assistant Vice President of Performance Improvement or her designee will write an acknowledgement letter to the patient /family within 7 business days and forward the complaints to the Department Director/Manager. The Department Director/Manager will investigate the complaint and submit the results of their investigation to the Performance Improvement Department within 10 business days of receiving the complaint. The Assistant Vice President of Performance Improvement or designee will write the response letter to the patient/family.

The time frame for a written response to grievances was not established in the policy.

During interview Staff E, AVP Performance Improvement/Risk Management on 1/7/16 at 12:15 PM, she acknowledged the findings.

Based on medical record review, document review, and interview, in 1 of 12 grievances, the facility did not implement its policy and procedure to ensure the resolution of grievances. Specifically, the facility did not provide a written response to a complainant following the investigation of her grievance.

Findings include:

Patient #1 is a 15-year-old female who was evaluated in the Emergency Department (ED) on 11/23/15 for syncopal (Fainting) episode and was discharged home on the same day.

The review of document titled, "Performance Correction Notice" revealed a complaint was received from patient's mother on 11/23/15 regarding inappropriate behavior of Staff Q, ED, Medical Assistant.

The facility investigation report notes that Staff S, an EKG technician who was present during the remark made by Staff Q, confirmed that while she was performing an EKG for the patient, Staff Q stated he could teach Staff S how to do the EKG. Staff Q stated, "Come out and pull your pants down and I will show you".

The review of personnel file for Staff Q revealed he failed probation and was terminated on 11/24/15.

The facility's procedure manual titled "Complaint and Compliment Process," last revised July 2014, stated the following: The Department Director/Manager will investigate the complaint and submit the results of their investigation to the Performance Improvement Department within 10 business days of receiving the complaint. The Assistant Vice President of Performance Improvement or designee will write the response letter to the patient/family.

The review of the Complaint/Grievance log noted the grievance was not entered into the Performance Improvement Department log as directed by the facility's protocol, consequently, there was no acknowledgement letter sent to the complainant, and upon investigation of the complaint, a written notice of the outcome of the investigation was not sent to the complainant.

During interview of Staff H, ED, Assistant Director of Nursing on 1/7/16 at 01:14 PM, he stated the report of investigation was not sent to the Assistant Vice President of Performance Improvement and he acknowledged that there was no written response to the patient's mother.

Based on review of documents and personnel files, it was determined that in 2 of 11 employee files, the facility did not implement its policies and procedure to ensure employees health assessments were performed annually when due.

Findings include:

Review of health file for Staff N on 1/8/16 noted that the last health assessment was done on 2/19/10.

The health file for Staff W noted the employee's health assessment was last done on 10/8/14. Upon notification of Staff J on 1/8/16, an updated health assessment was submitted dated 1/8/16.

The facility did not implement its policy titled "Employee Health", last revised April 2015, that notes the following: "Annually, on employee's anniversary date, in accordance with New York State Department of Health regulations, all personnel are required to complete an annual assessment of their health status."