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Based on interview and document review, it was determined the facility failed to utilize the Grievance Committee for the review and resolution of a submitted grievance, and failed to notify the grievant in writing of the status of the grievance within seven (7) days for one (1) patient (Patient #1).

The findings include:

On 05/07/24 at 12:39 pm, the surveyor met with Staff Member #15 for interview. Staff Member #15 advised they received a verbal, telephone report of Patient #1's complaint following the patient's encounter while in the ED (Emergency Department).

On 05/08/24 at 10:29 am, the surveyor met again with Staff Member #15 who advised that the Grievance Committee never met to review Patient #1's documented grievance, nor was the grievant ever provided a follow-up letter regarding the review, status, or resolution of the grievance.

The surveyor was supplied the facility policy titled, "Individual's Rights and Responsibilities" (with last effective date of 05/05/23). Under "Dispute Resolution" of page four (4), the policy stated that all patients have the right to have disputes, grievances, and conflicts resolved "respectfully, in a timely manner, and in writing".

The surveyor was also supplied the facility policy titled, "Patient Complaint and Grievance" (with last effective date of 05/22/23). The policy stated, in part, that regardless of whether made verbally or in writing, any complaint received "involving or alleging a violation of a patient's rights is a grievance".

The policy continued to state that grievances are to be reviewed by the Grievance Committee, and that the "Grievant must receive a written response which shall promptly be made within the average time frame of seven (7) days. If the grievance cannot be resolved within this seven-day timeframe, the grievant must be notified that the hospital is still working to resolve the grievance ..."

On page five (5) of same policy, an algorithm depiction indicated that any verbal dispute or conflict which was not resolved in real-time regardless of whether or not it was received during admission would be classified as a formal grievance.

On 05/08/24 at approximately 12:00 pm, the surveyor disseminated the findings to Staff Member # (1, 2, 4, 11, 12, 14, 26, 27). Opportunity for questions and clarification provided.

Based on interview and document review, it was determined the facility failed to obtain consent for treatment for two (2) of eight (8) patients treated at the facility (Patient #3 and Patient #6).

The findings include:

On 05/07/24 at 9:45 am, the surveyor initiated the medical record review of Patient # (1-8) with the assistance of Staff Member #12 who served as EMR (electronic medical record) navigator.

The surveyor received information from Staff Member #13 that consent for treatment can be found on the "Universal Patient Encounter" (formerly known as "BSMH Patient Agreement") document.

During review, the surveyor was unable to locate any completed "Universal Patient Encounter" documents for Patient #3 and Patient #6 nor any other related documentation.

In the morning of 07/07/24, the surveyor met with Staff Member #13 who confirmed that all patients, whether inpatient or outpatient, are expected to have informed consents for treatment unless documentation exists that support the patient's inability to otherwise consent.

The surveyor requested Staff Member #13 to verify whether there was any consent for treatment documentation available for either patient.

On 05/07/24 at 11:17 am, Staff Member #13 returned to provide verbal statement that they were unable to locate any evidence of Patient #3 and Patient #6 having ever consented for treatment. Staff Member #13 added there was also no documentation of the rationale for the missing consent forms.

The surveyor was provided by Staff Member #13 the facility policy titled, "Individual's Rights and Responsibilities" (with last effective date of 05/05/23) which stated that patients have the right to be involved in decision-making and care, including consenting for treatment services.

The surveyor was also provided both the Standard Operating Procedure (SOP) titled, "Patient Access: Consent for Treatment" (with last effective date of 09/01/19) and the "Front End: Consent for Treatment Fact Sheet" (with last effective date of 03/19/24) documents.

The documents stated, in part, that all patients are expected to consent to, via signature, the receiving of medical care and treatment services. If unable to sign, there must be accompanying documentation in the medical record.
In the afternoon of 05/07/24, the surveyor reiterated the findings to Staff Member #13 who demonstrated understanding.