HospitalInspections.org

Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for grievances and complaints in 1 instance.

Findings:

1. Review of policy titled Customer Complaint/Grievance Process, reviewed/revised 1/2021, states any verbal complaint by any customer will be taken by any staff at any time and forwarded to the Risk Manager for logging in and distribution to the appropriate person for resolution.

2. Facilities complaint/grievance log and event log lacked documentation of a complaint or grievance involving Patient 1 and investigation of Patient 1's complaint of being raped.

3. Review of Patient 1's Medical Record (MR) indicated on 6/07/2021 that patient stated he/she was raped and MR lacked documentation of further investigation of patient's statement/complaint of being raped.

4. Interview on 6/22/2021 at 1300 hours with Personnel A4 (Case Manager) indicated patient informed her of complaint and she reported to her supervisor and to Medical Staff P1 (MD, Psychiatrist). Personnel A4 indicated Medical Staff P1 responded by stating patient was delusional. Interview on 6/22/2021 at 1450 hours with Staff N8 indicated patient stated to her another patient was a rapist and pointed to the other patient he/she was referring to. Staff N8 stated she did not report this to the psychiatrist and that it was documented in the nursing notes which the psychiatrist read.



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