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Based on observation, interview, and document review the facility failed follow policy to investigate and respond to all grievances received by the facility and failed to provide care in a safe setting resulting in the potential to deny patients the right to file a grievance and the potential for unsatisfactory outcomes including injury and/or death for psychiatric patients located on the geriatic psychiatric unit. Findings include:

See specific tag:

1. The facility failed to ensure all grievances were investigated and responded to for 5 of 7 grievances received by patient or the patient's guardian (pt#1, #36 , #37, #38, #39). See tag A-0118.

2. The facility failed to ensure a ligature-free and risk free environment for 3 of 5 patients (#21, #22, #24) with self-harm and/or suicidal ideation diagnosis the facility failed to ensure a self-harm free environment. See tag A-0144.

Based on document review and interview the facility failed to follow policy by failure to investigate one of seven grievances and failure to respond to five of seven grievances received resulting in the potential denial of all patients to have grievances investigated and addressed by the facility. Findings include:

During review of the complaints and grievance log on 4/26/2022 at 1530 a total of 7 complaints and grievances were selected for review.

On 4/27/2021 at 1130 during document review of the facility complaint and grievance log it was revealed that the facility failed to investigate one of seven "complaints" and failed to respond to five of seven complaints received by the facility.

On 4/27/2022 at 1100 a review of the facility identified "complaint" from the parent of patient #1 was conducted. During the review it was revealed that the "complaint" had been received after the patient had been discharged from the hospital on 3/11/2022. An interview was conducted the patient representative from the Patient Experience Department on 4/27/2022 at 1139. When queried as to why this "complaint" was not considered a grievance, staff Y stated it was considered a complaint according to facility policy. Staff Y stated that the "complaint" was not investigated because the patient's mother "was unable to articulate something (staff Y) could help her with, had become belligerent on the phone, and did not state that she wanted any follow-up. The logged "complaint" stated the patient's mother stated she was upset with the patient's care in the Emergency Department. When asked if any further follow-up in the form of a letter had been initiated and completed, staff Y stated, "No." The "complaint" was considered closed.

On 4/27/2022 at 1434 further review of the selected complaints and grievances revealed that a complaint was received on 3/28/2022 from Patient #36 parent concerning a lost t-shirt and a lost coat. The "complaint" was closed on 4/27/2022. The notes stated tried to leave a VM (voicemail) but the VM was full. A letter was not sent as a follow-up to the complaint.

On 4/27/2022 at 1440 a review occurred of a grievance from patient #37. The grievance was received on 2/8/2022 and closed on 2/10/2022. Notes revealed the patient was called concerning inaccurate results being placed in the patient's chart. A letter was not sent to the complainant for follow up.

On 4/27/2022 at 1450 a "complaint" from Patient #38 was received on 4/8/2022 concerning lost dentures after the patient had been discharged from the hospital. The complaint was closed on 4/12/2022. A letter was not sent to the complainant for follow-up.

On 4/27/2022 at 1500 a review occurred of a "complaint" received on 2/28/2022 by patient #39 concerning quality of care the patient received in the ED. Notes stated the patient was called but a letter was not sent to the complainant.

On 4/27/2022 at 1300 a document review was conducted of the policy titled, "Tier 1: RL Feedback Reporting (Compliment, Comment, Complaint, Grievance)," policyStat ID 106552217 with an effective date of 11/8/2021. According the the policy it states, "Complaint: Verbal feedback which expresses concern or dissatisfaction regarding clinical care, services, staff, or the physical environment that can be resolved during the encounter by staff present (e.g., hospital, clinic, emergency room). Resolution is straightforward consisting of an explanation, clarification of policy/procedure or simple apology using the HFHS HEART service recovery model. A verbal complaint is considered resolved when the patient is satisfied by actions taken on their behalf."

The policy futher states, "Grievance: Formal or informal written or verbal complaint that is made 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), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to the right to appeal readiness for discharge. Any complaint that alleges serious injury, harm, impairment, or death, or describes a possible violation of state law or rule also constitutes a grievance. Documentation in RL Feedback is required for initiation and documentation of the investigation and response." The policy further states, "B. All formal or informal complaints made to an HFHS representative (e.g., staff, manager) regarding the patient's care that cannot be resolved by staff present are considered a grievance and will be handled according to the Center for Medicare and Medicaid (CMS) Conditions of Participation (CoP) for the respective service setting (e.g., hospital, home health care).

1. In accordance with the Center for Medicare and Medicaid (CMS) Conditions of Participation (CoP) Patient Rights and Responsibilities, all patients are informed of their right to file a grievance about services received (See Attachment B - Patient Right to Grievance).

2. A verbal complaint about patient care (received from patient or patient representative in person or by phone) is considered a grievance when it cannot be resolved at the time of the complaint by staff present and must be postponed for later resolution and/or requires investigation.
Complaints received by phone that could have been resolved by staff present do not constitute a grievance unless a response is requested by the patient or patient representative.

3. A written complaint (e.g., email, fax, or letter) received from a patient or patient representative constitutes a grievance. Letters attached to patient satisfaction surveys constitute a grievance only if the patient is identified by name and requests a resolution.

4. All verbal and written complaints will be handled as grievances anytime the patient or patient representative requests a response.

The policy further stated, " 7. Complaints that cannot be resolved by staff present will be considered a grievance and will be handled according to the Grievance Response Process (See Attachment F - RL Grievance Feedback Process).
·
Oversight for all grievances will be provided by Care Experience staff for timely and appropriate resolution.
·
The person receiving the grievance, or their designee or Care Experience staff will enter the case into the RL Feedback, attach any documents (e.g., letter, fax) to the case file, and notify the appropriate department leader(s) for investigation and resolution.
Grievances will immediately be brought to the attention of the involved manager(s) and Care Experience staff by phone and/or email in order to meet the CMS 7-day timeline for response back to the patient.
a. Investigation of a grievance that alleges serious injury, harm, impairment, or death must start within 3 days of receipt of the grievance.
b. Investigation of a grievance that does not allege serious injury, harm,impairment, or death must start within 7 days of receipt of the grievance
ii. In addition, the Feedback Task Function may be used to notify the involved manager(s) and Care Experience staff of the case to facilitate timely investigation.
·
Once notified of the grievance, Care Experience staff or delegate will provide acknowledgement (by phone, email, letter or in person) to the patient, thank him/her for the feedback, inform the patient that the complaint will be investigated and provide a timeframe for response.
·
All grievances will be investigated with an average response back to the patient within 7 days. Written response is required, with attachment of the letter to RL Feedback case.
i. If an investigation is more complicated and will require more than 7 days to resolve and/or evaluate a corrective action plan, response to the patient will be provided that includes status of the investigation and an approximate timeframe for final response.
ii. All grievances about potential risk or safety issues that are referred to the operating unit Quality/Risk staff for review and action using the RL Risk process will include notification that the case is a grievance. The Care Experience staff will monitor the case for timeliness will collaborate with Quality/Risk to determine patient/family updates re: case progress and investigation outcome. (See Attachment G - Feedback Cases Requiring Quality Risk Investigation)
iii. In all grievance cases, the Care Experience staff will collaborate with appropriate team members as applicable (e.g., managers, Quality/Risk, Legal) to prepare a final written response incorporating the outcome of the investigation as well as any identified corrective actions to be taken.
iv. The final written response to the patient must be provided within 10 days of completion of the investigation (for LARA complaints involving serious injury, harm, impairment, or death) or within the 30-day timeframe and will include:
a.
Steps taken on behalf of the patient to investigate the complaint
b.
The results of the grievance process
c.
The date of completion of the investigation
d.
The name of the contact person (e.g., for the operating unit)
v.
If the initial grievance was received via email, the written response may also be provided via email. A copy of the email response will be attached to the Feedback case.
vi.
In all grievance cases, the Care Experience staff will monitor the cases to ensure appropriate follow-ups, and once complete, will close the case.
·
If the involved manager(s) and Care Experience staff are unable to resolve a patient grievance, the patient has a right to have the grievance reviewed at a higher level of the organization with the intent of resolving the complaint to the satisfaction of the complainant.
i.
Grievance hearing functions will be performed by the appropriate operating unit administrators / executives according to the chain of command for the involved area(s) (e.g., the President, the Chief Nursing Officer, and/or the Chief Medical Officer, or their designee(s)) as well as the Care Experience staff and involved manager(s).
ii.
If the patient or patient representative remains unsatisfied despite an appropriate investigation and reasonable actions on the patient's behalf, the grievance may be considered closed.
8.
The grievance process is available to all patients and patient representatives without reprisal or denial of services (See Attachment B - Patient Right to Grievance).
·
Patients are informed of their right to file a grievance through written materials (brochures, handbooks, and literature), posted displays and through the Care Experience department.
·
All patients are informed of their right to file a complaint with the state agency directly and are provided contact information and resources to assist with writing a complaint, regardless of whether they first used the HFHS grievance process."

Based on observation, interview, and document review, the facility failed to ensure a ligature-free and risk free environment for 3 (#21,#22, and #24) of 5 patients who were found to be suicidal or a risk to harm themselves resulting in the potential for self-harm up to and including death. Findings include:

During the initial tour of the facility on 4/26/2022 at 1005, while on the geriatric behavioral health unit it was revealed in room 3308 that two beds in the room contained beds with open areas and a brake pedal located at the end of each bed.

On 4/26/2022 at 1007, staff L, the behavioral health manager was interviewed if he was aware of that the beds posed a ligature risk for patients on the unit. Staff L explained the beds were used for patients that may need positioning and served to assist staff in caring for geriatric patients. When queried as to how many hospital beds were present on the unit, staff L stated, "Ten...Every bed on the unit is a medical bed."

On 4/26/2022 at 1011 during further tour of the unit it was observed five metal boxes adhered to the hallway corridor walls containing 3 boxes of gloves easily accessible to staff and patients alike. Additionally, five hand sanitizers were adjacent to the glove stations freely open to both staff and patients. Staff L was queried if the boxes of gloves and the hand sanitizers should be located in the hallways posing a source to either ingest or use gloves to make a means for ligature. Staff L responded, "they have always been located there..." Staff L was asked if patients could access gloves or the hand sanitizer. Staff L responded, "I see what you are saying...they have always been there since the unit has been open."

On 4/26/2022 at 1046 document review occurred of the medical records of all five patients currently on the geriatric unit.

On 4/26/2022 at 1047 during the document review of patient #21's medical record it was revealed the patient had been admitted on 4/18/2022 for suicidal attempt by overdosing on Norco (a narcotic) and Metoprolol (a beta blocker used to decrease blood pressure).

On 4/26/2022 at 1055 during the document review of patient #22's medical record it was revealed the patient had been admitted on 4/22/2022. The patient's psychiatric evaluation stated the patient had, "a litany of risk factors for suicide."

On 4/26/2022 at 1110 during the document review of patient #24 medical record it was revealed the patient had been admitted on 3/11/2022. The patient's psychiatric evaluation stated the patient had, "intermittent suicidal ideation."

Based on observation and interview the facility failed to ensure Emergency Medical Treatment And Labor Act (EMTALA) signs in waiting room areas were likely to be noticed by all individuals that visit the Emergency Department (ED) resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 4/26/2022 at 0940 during the initial tour of the ED waiting room area it was revealed there was one EMTALA sign immediately to the left of the registration desk which could not be easily seen from all places in the patient waiting area. Additionally, there were multiple private rooms off of the waiting room that were used for patients requiring isolation and for families with small children. These rooms did not have EMTALA signage present inside ther rooms and the only EMTALA sign near the registration desk could not be visualized easily even with the door to the room opened.

On 4/26/2022 at 0950 staff A, the Interim Director ED / CDU (Clinical Decision Making Unit) and Staff C, the manager of the ED were informed in regard to required EMTALA signage and if the signage was appropriately sized for visibility and the likelihood to be noticed by all individuals that visit the ED. Staff C responded, "I understand and we will get it corrected immediately."