HospitalInspections.org

Based on document review and interview, the facility failed to adhere to their policy and procedure established for grievances in 1 (Patient 4) out of 10 medical records reviewed.

1. Review of policy titled: Patient/Parent Rights and Responsibilities, Complaints and Grievances last approved 11/30/16 indicated that a complaint is considered a grievance whenever the complaint involves a violation of the Patient Bill of Rights. The Patient Advocate will contact the patient by telephone and communicate with the patient at least every 5 business days until a resolution is met; and contact the appropriate physician, nursing staff or ancillary department to participate in resolving the grievance. The Patient Advocate will communicate results in a written letter that includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate, the results of investigation and the date of completion.

2. Review of email initiated by Nursing Administration dated 02/25/19 at 9:48 pm indicated a call from facility 2 regarding complaint from discharged patient 4 that they had been sexually assaulted at facility 1 on 02/16/19 or 02/17/19 by an African American who smelled like alcohol at 6:45 am. Facility 2 indicated that their local law enforcement (PD1) had been notified.

3. Interview with P53, Interim Executive Director of Risk Management on 02/28/19 at 10:25 confirmed lack of complaint or grievance for Pt4 per P56 and P57, both Patient Advocates for facility.

4. Interview with P53 on 02/28/19 at 2:45 pm confirmed no incident report was completed.