HospitalInspections.org

Based on interview and document review, it was determined the facility staff failed to ensure they followed their policy related to resolving a patient's grievance.

The findings include:

Staff Member #12 was interviewed on 12/19/17 at approximately 2:10 P.M. and stated, "The patient dropped off their complaint in person on October 16, 2017. The Grievance Committee immediately began to look at the issues identified by the patient. Because the patient identified they had reported the issue to an attorney, we turned the investigation over to our legal department and they stated they would take care of it from there. We sent the patient a letter on October 23, 2017 acknowledging receipt of the complaint and that an investigation was completed. We did not send the patient a letter with our findings."

The policy titled "Patient Complaint and grievance Resolution" with a revision date of 10/2017 was provided by Staff Member #1.

Under Procedure Bullet #4, Grievance Process section e states the Service Quality Manager will send a final letter, via certified mail, to the complainant within 30 days of the notification of the complaint/grievance unless the first response letter was actually the final letter of closure.

Based on medical record review and interview, it was determined that the facility failed to inform patients or the patients representative of their patient rights and obtain consent for treatment on admission for two (2) of ten (10) patients (Patient # 10 and #14).

The findings include:

During medical record review on December 19, 2017 between 9:00 A.M. and 1:00 P.M. the following was revealed:

Patient # 10 was admitted to the hospital Emergency Department (ED) on December 15, 2017 at 11:16 A.M. and admitted to the hospital as an inpatient on December 15, 2017 at 3:34 P.M. Patient # 10 arrived at the ED by ambulance. The history and physical documented by the physician in the ED states "Patient unresponsive". There is no documentation of any attempts to contact a patient representative. A review of the hospital form titled "Conditions of Admission/Registration" which includes the consent for treatment and patient rights revealed what appears to be "RW unable" dated December 15, 2017 at 11:50 A.M. There is no other documentation on the form.

An interview with Staff Member # 13 on December 19, 2017 at approximately 10:45 A.M. revealed "It says unable".

Patient # 14 was admitted to the hospital ED on December 10, 2017 at 2:03 P.M. and admitted to the hospital as an inpatient on December 11, 2017 at 12:04 A.M. Patient # 14 arrived at the ED by ambulance. The history and physical documented by the physician in the ED states "Patient unresponsive". There is no documentation of any attempts to contact a patient representative. A review of the facility form titled "Conditions of Admission/Registration" which includes the consent for treatment and patient rights revealed what appears to be "moe" dated December 10, 2017 at 3:10 P.M. There is no other documentation on the form.

An interview with Staff Member # 13 on December 19, 2017 at approximately 11:20 A.M. revealed "I don't know what that says, the patient was unresponsive".

The facility policy titled "Informed Consent" provided by Staff Member # 20 on December 19, 2017 at approximately 2:30 P.M. reads in part; "A patient signs the "Condition of Admission or Registration" form at the time of admission to the hospital or registration in the Emergency Department. Special Circumstances: When a patient remains incapable of making informed decisions and there is no surrogate decision-maker available, two (2) physicians shall document the need for the treatment. Telephone consent is permissible...two nurses and/or healthcare professionals shall speak to the surrogate decision-maker. The nurse(s) and or healthcare professionals will: sign the surrogate's name, document the relationship to the patient, complete the date and time, document the consent was obtained by telephone and witness the form with signatures."

The findings were discussed with Staff Members # 1, #2, #3, #11 and #18 on December 19, 2017 at approximately 3:45 P.M. during the exit interview.