HospitalInspections.org

Based on medical record review and staff interview, it was determined that the facility failed to ensure that
patients or their designated representative receive; (a) the standardized IMM notice (Important Message from Medicare) within 2 days of admission and (b) the information on patient's rights (Patient Information package).
These finding was found in five (5) of seven (7) medical records (MR) reviewed. (Patient #1, 2, 3, 4, 5)

Findings include:

A tour was conducted on 2/8 and 2/9/18 on the Adult Psychiatric units of the 6th and 8th floor. Present during the tour were Staff A, Risk Manager and Staff C, Administrative Director of Psychiatry. Review of medical records of patients receiving Medicare showed that Patient #1, 2, 3, 4, 5 did not receive the standardized IMM notice.


During the tour on 2/8/18 of the 6th floor Psychiatric Unit, Staff D, Patient Care Manager was interviewed on patient's receipt of the Patient Information package. Staff informed the surveyor that patients are informed of their rights verbally. The Patient Information package is provided only if the patient requests it.

There was no written evidence in any of the patients medical records on the unit that patients were informed verbally of the patient's rights or received the Patient Information package.

Based on staff interview and document review, it was determined that the facility failed to ensure patient grievances are investigated. This was found in five (5) of five (5) grievances reviewed. (Patient 18, 19, 20, 21, 22)


Findings include:

On 2/9/18 at approximately 11:00 AM an interview was conducted with Staff D, Manager Patient Relations. Review of patient grievances for 11/6/17 identified 5 grievances. Upon review it was found that all grievances were missing the investigation. These grievances contained only the patient's complaint and a copy of the letter sent to the patient by management, acknowledging the receipt of their grievance. No other step was taken pertaining to these grievances.

The hospital policy and procedure titled, "Patient Complaints and Grievances," revised 3/2017 states; "the Hospital shall have a mechanism wherein grievances, both written and oral, can be voiced and investigated with a response formulated to the complainant. Administrative staff will be apprised of problems identified and will develop corrective action plans, where necessary, to prevent recurrence."

Staff did not follow the policy concerning the investigation of grievances. Staff D, Manager Patient Relations acknowledged the findings.

Based on staff interview and document review it was determined that the hospital did not ensure that all patients are provided with a written notice of the outcome of their grievance, as per regulatory and facility's policy. This was found in five (5) of five (5) grievances reviewed. (Patient #18, 19, 20, 21, 22)

Findings include:

On 2/9/18 at approximately 11:00 AM an interview was conducted with Staff D, Manager Patient Relations. Five (5) grievances were reviewed with Staff D. Upon review it was found that all grievances were missing the letter of completion of the patients' grievance.
The hospital policy and procedure titled, "Patient Complaints and Grievances," revised 3/2017 states, A written response will include:
a) Name of contact person.
b) Steps taken to investigate.
c) Outcome/results of the grievance process.
d) Date of completion.

Staff D, Manager Patient Relations, acknowledge the findings. An investigation of the grievance was not done therefore a letter to the patient (complainant) was not sent.