HospitalInspections.org

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Based on interview, review of three patient grievances, review of hospital policies and procedures, the hospital failed to ensure that patients were provided with a written response to their grievances for 3 of 3 grievances reviewed (Patients #1, #2, #3)

Failure to provide patients with a written response to their grievance violates their right to be informed of how the hospital investigated and resolved the grievance.

Findings:

1. On 10/7/2016 at 10:20 AM, Surveyor #4 reviewed three patients grievances submitted by Patient's #1, #2, and #3. These grievances alleged that the patients had been abused by staff during their hospital stay. The grievance information provided did not include the evidence that the patients had been informed of the results of the hospital's investigation of their complaints.

2. On 10/7/2016 at 11:00 AM during an interview with Surveyor #4, the hospital's Chief Operating Officer (Staff Member #1) confirmed that the patients had not been provided with a written response informing them of how the hospital had investigated and resolved their grievances.

3. Review of the hospital's policies and procedures entitled "Patient Complaints" (Policy No. 1.38; Reviewed 7/2016) and "Patient Abuse: Procedure Reporting" (Policy No. 1.29; Reviewed 9/2015) revealed that the policies did not identify how patients were to be informed of the steps taken during the complaint investigation process and results of the investigation.
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Based on interview, review of 16 incidents of patient allegations of abuse, review of hospital policies and procedures, the hospital failed to provide evidence that an allegation of abuse was investigated according to hospital policy for 1 of 16 allegations reviewed (Patient #1).

Failure to investigate allegations of patient abuse and to act on investigation findings risks physical and psychological injury to patients due to care in an unsafe environment.

Findings:

1. The hospital's policy and procedure entitled "Patient Abuse: Procedure Reporting" (Policy No. 1.29; Reviewed 9/2015) read in part: "Verifying the Occurrence of Abuse: 1. If there is a question as to whether abuse has occurred or not, the physician/OD [Officer of the Day] determines if "reasonable cause"... exists to suspect or believe abuse may have occurred. If reasonable cause exists, the physician documents the findings and decisions(s) as described below, instruct the appropriate supervisor(s) to complete the requirements identified above. 2. If there is not a reasonable cause to suspect or believe abuse has occurred, the RN and physician will both document their findings in the patient record..."

2. On 10/7/2016 at 10:20 AM, Surveyor #4 reviewed a written grievance submitted on 9/2/2016 by Patient #1 that alleged the patient had been raped. The patient identified the perpetrator of the rape by name. The grievance information provided to the surveyor by the hospital indicated that the complaint had been reviewed by the hospital's complaint review team and was forwarded to the RN3 charge nurse of the patient's ward, the patient's attending psychiatrist, and an RN4 nursing supervisor.

3. On 10/7/2016 at 11:00 AM during an interview with Surveyor #4, the hospital's Chief Operating Officer (Staff Member #1) stated that because the person identified by the patient as the perpetrator of the rape was not a hospital staff member, no further investigative action had been taken.

4. On 10/17/2016 at 2:45 PM during an interview with Surveyor #4, the patient's attending psychiatrist (Staff Member #2) stated that s/he had been notified of the patient's rape allegation. The psychiatrist stated that the patient had an extensive history of delusions related to sexual assaults. The psychiatrist stated that because of this patient's history and that there had been repeated unsubstantiated allegations of sexual assault, this complaint had been closed. The psychiatrist confirmed that s/he had not documented this information in the patient's medical record as directed by hospital policy.
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Based on personnel record review and review of hospital policy and procedure, the hospital failed to ensure that staff members were current in cardiopulmonary resuscitation certification (CPR) for 2 out of 10 files reviewed (Staff Members #4, #5).
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Failure to maintain current CPR training risks inability of hospital personnel to respond correctly to a cardiac or respiratory emergency.
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Findings:
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1. The Eastern State Hospital Manual policy titled, "Cardio-Pulmonary Resuscitation (CPR)" (Last Reviewed 4/15) read in part: "CPR is an emergency life-saving measure. Medical, Rehabilitation Services, Security staff and Nursing staff are required [sic] maintain certification in Basic Life Support instructor/provider unless completing Advanced Cardiac Life Support training through the American Heart Association. There is a two year cycle to ensure all clinical staff is in compliance with the new two year certification."
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2. On 10/06/2016 at 1:30 PM, Surveyor #1 reviewed personnel files with the Human Resources Manager (Staff Member #3). Review of the personnel file of a registered nurse (Staff Member #4) and a mental health technician (Staff Member #5) revealed that both staff members received cardiopulmonary resuscitation training on 5/13/2014 and 9/22/2014 respectively and had not received an updated training within the two year cycle as required by policy.
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