HospitalInspections.org

Based on record review and staff interview, the facility's governing body failed to ensure grievances were reviewed and resolved for 5 of 8 grievances.

The findings include:

A review of the facility's Policy on "Administration of Complaint/Grievance Process", effective March of 2011, revealed "the grievance/complaint process shall be the responsibility of the Risk Manager assuring that someone with problem solving authority is part of the process." The policy further states "The risk manager or designee shall maintain all consumer complaint and grievances, both formal and informal. Summaries of such will be reported to the Quality council, Medical executive Committee and the Board of Trustees quarterly." The Policy continues with "The Risk Manager shall provide assistance to individuals who are unable to submit a written complaint/grievance. This will include assistance in preparing a written complaint/grievance and communicating back to the resident."

A review of facility grievances since January 2013, revealed a grievance dated 2/1/13 regarding staff turning on a red light in a patient's room, at night, and the patient being disturbed by the red light as he was a combat veteran and the light caused him to have flashbacks all night and was not able to sleep. Further review of the grievance revealed the grievance form was blank on the back where the Department Manager Section is located and gives information as to when the grievance was resolved, was the person reporting the problem satisfied, if it needs to go to the hearing review panel and signatures.

A review of a grievance dated 2/4/13 revealed someone complained of not receiving a snack when requested. It is unknown who made the grievance as the space for the "signature of Person Reporting Problem" was left blank. Further review of the grievance revealed the back of the form was blank where the Department Manager Section is located and gives information as to when the grievance was resolved, was the person reporting the problem satisfied, if it needs to go to the hearing review panel and signatures.

A review of a grievance dated 2/5/13 revealed a patient complained of missing person items. Further review of the grievance revealed the back of the form was blank where the Department Manager Section is located and gives information as to when the grievance was resolved, was the person reporting the problem satisfied, if it needs to go to the hearing review panel and signatures.

A review of a grievance dated 2/5/13 revealed a patient complained of the amount of time given to smoke.
Further review of the grievance revealed the back of the form was blank where the Department Manager Section is located and gives information as to when the grievance was resolved, was the person reporting the problem satisfied, if it needs to go to the hearing review panel and signatures.

A review of a grievance dated 2/5/13 revealed a patient complained of the limited time he had to eat his meals. Further review of the grievance revealed the back of the form was blank where the Department Manager Section is located and gives information as to when the grievance was resolved, was the person reporting the problem satisfied, if it needs to go to the hearing review panel and signatures.

An interview with the Interim Risk Manager on 3/12/13 at 3:10 PM, revealed he had not reviewed grievances.

An interview with the facility Administrator on 3/13/13 at 1:45 PM revealed that the facility had not followed their policy for grievances.