HospitalInspections.org

Based on a review of patient records, facility records and staff interviews, the facility failed to honor patient rights related to requesting to talk with the administrator of the hospital for 2 (Patients #1 and #11) of 11 records reviewed

The findings include:

1. A review of the grievances showed Patient #11 had a grievance concerning emergency services dated 4/4/11. A review of the grievance showed Patient #11 wanted to talk with the administrator of the hospital. A memo was written to the administrator on 3/14/11, to inform him Patient #11 called for him and "insisted" on speaking with him (the administrator).

An interview was conducted with the Director of Nursing (DON) on 7/11/11 at 1:00 p.m. She stated there is no documentation to show the administrator talked with Patient #11. An interview was conducted with the administrator's assistant at this time and she also stated she was not sure if the administrator talked with Patient #11. The administrator of the hospital was not at the facility at the time of the survey.

An interview was conducted with the administrator's assistant at 1:05 p.m., concerning any other patients wanting to talk with the administrator. She stated another patient (Patient #1) came into the office to talk with the administrator but he was not in his office. Patient #1 was very angry and started screaming. She asked him for information concerning his complaint but he only wanted to talk with the administrator. They had to call security. Once security came to the office the patient left. Patient #1 then called a staff from the hospital and left his name and phone number. She said the administrator called him but the phone number didn't work. It was a "fast busy tone." The administrator did not do anything else. She said she looked up the phone number and found it was listed under a different name than the complainant. They had an address connected to the phone number but she was not sure if anyone checked this address to the address of Patient #1's medical record.

A review of the policy "complaints - customer feedback" number 100.101.01 was conducted. It revealed, after a person makes a complaint the hospital is to phone the customer twice if there was no initial contact. If they can't contact the customer after two attempts then the hospital will send a letter to the costumer. This information was found on page 2, #4, f, ii. Continued interview revealed they did not send a letter to Patient #1. When asked if there was a policy that patients or customers not able to talk with the administrator concerning a grievance she stated "no." Therefore, the facility did not follow their policy for grievances and Patient #1 and #11's rights were violated by not being able to resolve their grievances by talking with the administrator.