HospitalInspections.org

Based on document review and staff interview, the hospital's Geri-psych Unit failed to follow the hospital's grievance policy for two of two complaints received in the last six months.

Findings include:

- The hospital Geri-Psych Unit's policy for Special Care Unit Grievance reviewed on 10/1/12 at 11:00am directed, "...In the event a patient or patient representative voices a complaint or concern, the Program Director trough the use of the quality improvement process shall initiate a investigation into the matter. The Director shall respond to the concern or complaint within a reasonable time frame considering the nature of the situation, and action deemed appropriate for the management of the situation. All attempts to contact the complainant if he or she is no longer an inpatient on the premises shall be documented. If after 30 days, the director is unable to make contact with the complainant, then a certified letter proving written instruction shall be mailed with "Return Receipt Requested" to the complainant asking him/her to contact the director. If no contact from the complainant occurs within 2 weeks, the case will be closed and information forwarded to the risk manager of the hospital..."

- Administrative staff B interviewed on 10/2/12 at 8:30am revealed they did not have a formal complaint log for the Geri-psych Unit. Staff B indicated they had received two complaints in the past six months. Staff B acknowledged they usually received a complaint, wrote it on a piece of paper, checked into the situation, and then threw the paper away. Staff B acknowledged they did not document an investigation or contact the complainant regarding the result of the investigation.

The hospital Geri-psych Unit failed to follow the hospital's grievance policy.

Based on medical record review, Patient's Right document review, and staff interview the hospital Geri-psych Unit failed to actively include the patient and/or the patient's representative in the development of their plan of care for three of four medical records reviewed requiring Durable Power of Attorney (DPOA) involvement (patient #'s1, 2, and 5).

Findings include:

- The hospital Geri-psych Unit's policy for Psychotherapy reviewed on 10/2/12 at9:15am directed, "...Family conference-Family meeting initiated for the purpose of discussing the patient's course of treatment, family's view of the patient's progress and discharge plans..."

- The hospital Geri-psych Unit's policy for Master Treatment Plan reviewed on 10/1/12 at 11:00am directed, "...Master Treatment Plan includes methods for involving the patient's family/significant other in the therapeutic process..."

- The hospital Geri-psych Unit ' s policy Social Work Services reviewed on 10/1/12 at 11:00am directed, "...Social work services will be provided...and will include...making contact with the patient's family with in 72 hours of admission..."

- The hospital Geri-psych Unit's policy Charting by Social Workers reviewed on 10/1/12 at 11:00am directed, "...Social workers are responsible for documenting family contact within 72 hours..."

- Patient #1's medical record reviewed on 10/1/12 at 2:45pm revealed the patient's mental status required the designated DPOA to make medical decisions. The medical record contained a voluntary application for admission dated 9/21/12 and phone consent by their DPOA. Documentation on 9/21/12 at 3:20pm in patient #1's medical record indicated the social worker invited the patient and their DPOA to attend treatment team meeting the following Thursday. The medical record lacked evidence the Geri-psych Unit staff included the DPOA in care planning/treatment planning meetings on 9/27/12 for the purpose of discussing the patient's course of treatment, family's view of the patient's progress, discharge plans or involving the DPOA in the therapeutic process. The medical record lacked any documentation of family/DPOA contact after admission. The Geri-psych Unit lacked evidence the patient's representative participate in the development of patient #1's plan of care.

- Patient #2's medical record reviewed on 10/1/12 at 3:30pm revealed the patient's mental status required the designated DPOA to make medical decisions The medical record contained a voluntary application for admission dated 9/10/12 and consent to treat and signed by patient #2's DPOA. Documentation on 9/10/12 at 4:35pm in patient #2's medical record indicated the social worker invited the patient and their DPOA to attend treatment team meeting the following Thursday. The medical record lacked evidence the Geri-psych Unit staff included the DPOA in care planning/treatment planning meetings on 9/13/12, 9/20/12, and 9/27/12 for the purpose of discussing the patient ' s course of treatment, family's view of the patient's progress, discharge plans or involving the DPOA in the therapeutic process. The medical record lacked any documentation of family/DPOA contact after admission. The Geri-psych Unit lacked evidence the patient's representative participate in the development of patient #2's plan of care

- Patient #5's medical record reviewed on 10/2/12 at 10:30am revealed the patient's mental status required the designated DPOA to make medical decisions. The medical record contained a voluntary application for admission dated 8/20/12 and phone consent by their DPOA. Documentation on 8/20/12 at 3:40pm in patient #5's medical record indicated the social worker invited the patient and their DPOA to attend treatment team meeting the following Thursday. The medical record lacked evidence the Geri-psych Unit staff included the DPOA in care planning/treatment planning meetings on 8/23/12 and 8/29/12 for the purpose of discussing the patient's course of treatment, family's view of the patient's progress, discharge plans or involving the DPOA in the therapeutic process. The medical record lacked any documentation of family/DPOA contact after admission. The Geri-psych Unit lacked evidence the patient's representative participated in the development of patient #5's plan of care

Administrative staff B interviewed on 10/2/12 t 8:30am acknowledged patient #'s 1, 2, and 5 medical records lacked evidence the Geri-psych Unit provided the patient's DPOA with information and allowed them to participate in the development of their plan of care