HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to follow its own policy regarding the identification and resolution of patient grievances for 1 of 1 patient grievances reviewed [Patient #1].

Findings were:

Facility policy #1000.09 entitled Patient Complaint and Grievance Process, effective date 7/7/14, included the following:
I. DEFINITIONS:
"A. A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care...
C. A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or his/her representative regarding the patient care provided...
D. Letter, email or fax is considered written...
III. PROCEDURE...
D. All grievances are to be submitted verbally or in writing to the Patient Advocate, either by the patient, the patient's representative or a staff member to whom the grievance was reported...
F. The Patient Advocate will conduct an investigation of the grievance, reviewing the patient's medical record, to obtain information regarding the patient's clinical condition...
I. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours..."

A review of a letter addressed to the hospital CEO from an attorney representing the parents of Patient #1 revealed complaints made on behalf of the parents regarding the care provided Patient #1 while at the hospital in April 2016.

In an interview with the hospital CEO, on the morning of 12/6/16 in the hospital conference room, he stated, "I remember getting this letter and passing it on to our medical records department. I just read it as a request for records. I didn't realize it was a grievance." Upon review of the definition of a patient grievance and the facility's policy, the CEO stated, "We didn't treat this letter as a grievance. I see it now."

Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient or patient's representative had the right to actively participate in his/her own plan of care.

Findings were:

Facility policy #200.05 entitled Master Treatment Plan, effective date 10/07/15, included the following:
"I. POLICY...
2. The organization documents family participation (if any) in the patient's medical record...
III. PROCEDURE
A. The patient's needs are identified from the information contained on the initial intake form, initial nursing assessment, psychosocial assessment, adjunctive therapy assessments, and psychiatric and medical evaluations.
B. Care and treatment decisions are made on a collaborative basis, with input from all disciplines providing care and services to the patient, to allow for the development of a Master Treatment Plan that is interdisciplinary in nature..."
The policy included no further discussion of patient or family involvement in the treatment planning process.

A review of patient clinical records revealed that 9 of 10 patients [Patients #1-6 and #8-10] ages 13-18, did not include documented evidence of the parents or guardians having been notified of the date, time and location of the treatment planning meetings so that they might actively participate. The records also included no documented evidence of their active participation in the meetings.

In an interview with the hospital chief nursing officer, on the afternoon of 12/6/16 in the facility conference room, she was asked about family involvement in the treatment planning process, specifically the involvement of parents. She stated, "We've made so many improvements in that whole process. Now we have a case management department...They all meet in the treatment plan meetings together now and they'll put the parents on the phone with them."

In a subsequent interview with the CNO, on the afternoon of 12/6/16 in the facility conference room, there was further discussion of involving parents in the treatment planning process of their child/adolescent patient. It was noted that recent clinical records reviewed still included no documented evidence of parental involvement in treatment planning. She stated she understood.

In an interview with Staff #4, Nurse Manager, during a tour of the child and adolescent unit on the afternoon of 12/6/16, she was asked about parental involvement in treatment planning and whether the parents were notified of the treatment plan meetings and actively participating in the meeting. She stated, "That I'm not so sure about."

The above findings were confirmed in an interview with the CEO and other administrative staff on the afternoon of 12/6/16 in the facility conference room.