HospitalInspections.org

Based on observation, interview and record review, the facility failed to inform patients of their right to file an internal grievance or that they may lodge a grievance with the State Agency directly. This deficient practice is likely to lead to all patients being uninformed of their rights to file a grievance and deprive them of the ability to advocate for themselves.

The findings are:

A. During an observation on 10/16/2023 at 2:00 pm down the main entrance hall of facility there was one sign notifying patients and family about their rights to file a grievance with the State Agency in Spanish. There was not a sign in English. There were no other signs in the hall or on the units.

B. During an interview on 10/16/2023 at 2:00 pm, Staff (S)3 Director of Quality Management confirmed there was only one sign informing patients and visitors about their rights to file a grievance with the State Agency in Spanish. The policy regarding informing patients and patient's representatives of their internal grievance procedure and how to lodge a grievance with the State Agency was requested but not provided.

C. Record review of "Patient and Family Handbook" dated 10/16/2023, provided to patients and family members on admission, does not provide any information on the patient's right to file an internal grievance or a grievance with the State Agency.

D. During an interview on 10/16/2023 at 2:30 pm with S2 Chief Clinical Officer, confirmed there were no information about the grievance process or how to make a complaint to the Department of Health (DOH) in the patient handbook.