HospitalInspections.org

Based on document review and interview, the facility failed to comply with all applicable state laws for 1 (S3 [Behavioral Health Recovery Attendant) of 1 unlicensed nursing assistant employee files reviewed.

Findings include;

1. Review of IC 16-28-13-4, a health care facility shall apply within three (3) business days from the date a person is employed as a nurse aide or other unlicensed employee for a copy of the person's state nurse aide registry report.

2. Review of employee S3's (Behavioral Health Recovery Attendant) employee file indicated that S3 was hired on 9/11/2017, as a Behavior Health Recovery Attendant and employee S3's file lacked documentation of a nurse aide registry report.

3. Interview on 12/5/2018, at approximately 10:14 am., with N1 (Director Of Quality Management) confirmed the above.

Based on document review and interview, the facility failed to ensure the effective operation of the grievance process in 1 (patient 1) of 1 patient rights grievance reviewed.

Findings include:

1. Review of facility policy, Education of Patients to Their Rights and Responsibilities, Effective Date, 3/13/2017, indicated the following: Complaints alleging violation of Guaranteed Rights are to be investigated within 3 days of the receipt of the complaint. Complaints alleging violation of Conditional Rights are to be investigated within 5 working days of the receipt of the complaint.

2. Review of patient 1's complaint indicated patient was dissatisfied with one person to talk with, as part of care plan. Complaint was received on 5/9/2018. Complaint was answered on 7/2/2018.

3. Interview on 12/4//2018, at approximately 1:52 pm., with N1 (Director of Quality Risk) confirmed patient 1's complaint about patient having one person to talk with, as part of care plan was not addressed in a timely manner.