HospitalInspections.org

Based on record review and interview, the facility failed to ensure that
1. 1 of 2 patients (Patient #17) received a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion;
2. The Patient Advocate provided documented problem resolution and/or follow-up in the investigation of the grievance; and
3. A plan of correction was developed by administrative staff that addressed the allegations with named staff members.

Findings included:

Record review of the policy A127b, "Patient/Resident and Family Grievances / The Role of the Patient/Resident Advocate," reviewed 1/2021, showed:
"It is the policy of West Oaks Hospital to encourage responsive and open communication with patient/residents at all levels in the hospital with the objective of resolving grievances through appropriate problem-solving actions ....
6. Once the issue has been resolved, the Patient Advocate shall provide a timely written response to the patient/resident and/or family member. The response shall include:
a. the name of the contact person
b. the steps taken to investigate the grievance
c. the results of the grievance process (i.e. how the grievance was resolved) ...
7. The grievance and problem resolution/follow up shall be documented. This documentation shall include:
a. date and time grievance initiated
b. name of person voicing a grievance/how to contact
c. name of grievance
d. date and time that grievance was initiated
e. pertinent investigation information
f. resolution of grievance/follow up
g. signature of person addressing grievance
h. date and time of resolution
i. date and time patient/resident or family notified ..."

Record review of the complaint log 5/5/21 through 5/24/2021 showed a complaint filed by the parents of Patient #17 on 5/19/2021. Further review of the complaint showed two 7:00am-7:00pm Mental Health Technicians (MHTs), Staff J and Staff Q, told Patient #17 "inappropriate things about a family member." The parents requested that Patient #17 be moved to another unit, away from those two (2) staff members.

In an interview with Staff D, the Patient Advocate, on 6/3/2021 at 1:35pm, he stated he did not provide Patient #17's parents with a written notice of the hospital's determination regarding the grievance because he considered it a "complaint." He also stated he did not have any other documentation on the incident other than the handwritten complaint from the parents of Patient #17. He said he did not speak with the two (2) named staff members about the incident. He concluded by stating he understood the need to have followed through with a letter to the complainants.

In an interview with Staff B (Interim CNO) on 6/4/2021 at 11:00am, she presented a letter dated 6/4/2021 addressed to the parents of Patient #17 from Staff D (Patient Advocate).