HospitalInspections.org

Based on document review and interview, the facility failed to ensure a complaint/grievance/incident was thoroughly and promptly investigated for 1 of 1 grievance reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Customer Issue Resolution (Patient Grievance)" last revised 4/2015 indicated the following: " ...I. Policy Statement: A...A process for the prompt resolution for patient/family, visitor concerns and complaints has been developed...II. Definition of Terms: A. Patient Grievance: 1. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with Centers of Medicare/Medicaid Services (CMS) requirements...C. Resolution. 1. The complaint/grievance process has been followed; the issue investigated...III. Procedure...G. The individual receiving the concern/complaint will assist in investigation of the issue and identify any violation of the patient's bill of rights.

2. Facility policy titled "Patient Bill of Rights and Responsibilities" last revised 5/2019 indicated the following: "...B. All patients...have the following rights...4. Personal Safety: a. To be given care in a safe setting, free from abuse, neglect (verbal, mental, physical, or sexual)..."

3. Facility policy titled "Corrective Action" last reviewed/revised 11/2021 indicated the following: "...III. Procedure: A. Whenever an infraction occurs, leaders are responsible for evaluating the nature and severity of the entire situation...B. Following a thorough investigation, leaders have discretion to give a co-worker any level of corrective action...Human Resources is available to serve as a consultative partner to assist leaders during the investigation process...E. Levels of Corrective Action...3. Suspension...2. During the investigatory process, a suspension may also be used in the case of a serious infraction that could jeopardize patient care, cause harm to co-workers or other individuals, or other similar types of misconduct that may lead to immediate termination. The leader is able to place the co-worker on an unpaid suspension pending the results of the investigation..."

4. A review of a grievance form titled "PATIENT RELATIONS WORKSHEET" related to patient #1 on 3/14/22 at 10:45 a.m., indicated a grievance was received on 12/11/21 at 10:30 a.m. from Patient #1. The following was indicated:
(a) A note dated 12/11/21 at 2:33 p.m. indicated the following: "Patient requested to speak to nurse lead and would not tell the nurse caring for (him/her) what it was about. When I went to speak to (Patient #1), (he/she) stated that the night PCT (Patient Care Technician), (N1) grabbed (his/her) breasts when helping (him/her) get up to the bathroom from the bed...(Patient #1) said (he/she) was in shock but knew (he/she) didn't want (N1) touching (him/her) again. Patient stated (he/she) didn't say anything to (N1) except for "[I] don't want your help" and "I can do it myself." Patient said (he/she) wouldn't let (N1) help (him/her) and (he/she) pulled (his/her) own pants up and down and transferred (himself/herself) to the toilet and back to bed.

(b) A note dated 12/13/21 at 1:35 p.m. indicated the following: "Leader aware. Will investigate."

(c) A note dated 12/13/21 at 3:19 p.m. indicated the following: "(Patient Advocate) reached out to pt. (patient) after (A12, Nurse Manager/Rehabilitation Unit)...went to speak with (him/her). Pt shared the same information...and feels the PCT grabbed (him/her) on purpose and that (he/she) seemed very surprised as pt. said (he/she) had a mastectomy and only had one breast. (Patient Advocate) let pt. know we would have a review done for (him/her) and provide follow up. Also, that PCT will not be assigned to (him/her) during the rest of (his/her) stay. Pt was appreciative of that and the call.

(d) A note dated 12/14/21 at 5:54 a.m. indicated the following: (A12) spoke with patient on (12/13/21) who described that a man in beige clothes grabbed (him/her) by the chest. (He/She) reports that (he/she) only has one breast and (his/her) facial reaction was that (he/she) was surprised. (Patient #1) asked that (he/she) is not assigned to (him/her) as a caregiver. (A12) apologized and will discuss with employee what occurred. Discussed with patient advocate as well for (his/her) follow up.

(e) A note dated 12/16/21 at 11:27 a.m. indicated that an initial letter was sent to Patient #1.

(f) A note dated 12/22/21 at 3:40 p.m. indicated the following: "Discussed with employee these concerns and awareness to future situations that could be perceived as this."

(g) A note dated 12/23/21 at 3:57 p.m. indicated that a final letter was sent to Patient #1.

The grievance form lacked documentation of an investigation related to the allegations.

5. Review of patient #1's medical record indicated Patient #1 was admitted inpatient to the Rehabilitation Unit on 12/9/21 at 11:49 p.m. with a diagnosis of a cerebrovascular accident (CVA) and discharged to home on 12/22/21 at 3:14 p.m. Patient #1 was alert and oriented to person, place, time, and situation on 12/10/21 at 3:57 p.m. and throughout the rest of his/her inpatient stay.

6. During an interview with A12 on 3/14/22 at 12:53 p.m., he/she verified A15 (Nurse Lead) reported to (him/her) that Patient #1 complained of N1 inappropriately touched (him/her) on the night shift of 12/10/21 into 12/11/21. The allegations were on the 4th floor of the unit. A12 verified that N1 was reassigned to the 5th floor of the unit while they investigated the allegations. A12 verified that N1 was still on orientation at the beginning of December 2021 and was on orientation on 12/10/21. A12 verified the following dates/locations that N1 worked:
(a) On 12/6/21, N1 was still on orientation and was working on the 4th floor of the unit.
(b) On 12/10/21, N1 was still on orientation with N4 (Patient Care Technician) and was working on the 4th floor of the unit.
(c) On 12/13/21 to 12/20/21, N1 was off orientation and was working on the 5th floor of the unit.
(d) On 12/27/21, N1 was working on the 4th floor of the unit.

7. During an interview A12 on 3/14/22 at approximately 2:30 p.m., he/she verified that no interviews were completed of other staff that had worked on the night shift of 12/10/21 into dayshift of 12/11/21 and/or of other patients that were inpatient at the time. A12 verified that N1 had not been suspended pending an investigation. A12 also verified that N1 had not been interviewed related to Patient #1's allegations until 12/22/21.

8. During an interview with A16, (Human Resources Manager) on 3/14/22 at approximately 5:00 p.m., he/she verified that today was the first time that he/she had been made aware/notified related to the allegations against N1. A16 verified that he/she would have recommended that N1 be suspended pending investigation. A16 verified that the allegation against N1 was reported on 12/11/21, a Saturday, but the manager could have contacted human resources by phone.

9. During an interview with A16 on 3/14/22 at 6:14 p.m., he/she verified that the allegations made by Patient #1 related to N1 would have indicated to them that the facility would have wanted to suspend N1 immediately pending investigation. A thorough investigation would include finding out who all was working at the time of the allegation, including the House Supervisor and interview them directly to see if anyone reported anything to them. The investigation would also include reviewing the incident report, interview the patient that reported the allegations, interview the staff member that submitted the incident report and interview the staff member that the allegations were made against to get the staff member's side of the story. A16 verified that the staff member that the allegations are made against should be interviewed prior to suspension pending investigation outcome. A16 verified that they would want to suspend pending an investigation, the staff member the allegations were against for the safety of other patients. A16 verified that allegations of abuse could result in termination of the staff member.

10. During a telephone interview with N4 on 3/15/22 at 1:04 p.m., N4 verified that N1 had oriented with him/her. N4 verified that he/she was never interviewed related to the allegations.

Based on document review, the facility failed to provide in its resolution of a grievance, the results of the grievance process to the patient. (Patient #1)

Findings include:

1. Facility policy titled "Customer Issue Resolution (Patient Grievance)" last revised 4/2015 indicated the following: " ...I. Policy Statement: A...A process for the prompt resolution for patient/family, visitor concerns and complaints has been developed...III. Procedure...H...A written response will be provided to the patient/family/visitor by the individual receiving the complaint unless delegated to a more appropriate individual..."

2. A review of a grievance form titled "PATIENT RELATIONS WORKSHEET" related to patient #1 on 3/14/22 at 10:45 a.m., indicated a grievance was received on 12/11/21 at 10:30 a.m. from Patient #1 and a note dated 12/23/21 at 3:57 p.m. indicated that a final letter was sent to Patient #1.

3. A review of the final written response to Patient #1 dated 12/23/21 indicated the following: "...The Inpatient Rehab Manager completed a review of your concerns. (He/She) shared (he/she) was able to follow up with the staff person who was involved in (your) care and has addressed the situation. Please know we cannot share any further details due to...Employee Confidentiality policy..." The final written response to Patient #1 lacked documentation of the results of the grievance process.