HospitalInspections.org

Based on interview and record , the facility failed to ensure that a significant grievance /concern was referred for follow-up in a timely manner for 1 of 4 discharged patients ( (Patient # 7).

Findings include:

TX # 00210090

Record review on 02-25-15 of TX # 002010090 complaint narrative revealed mother of Patient # 7(14 year old) alleged she was told by a staff person during the admission process: "you either leave your child here or we will report you to CPS(child protection services)." After a two(2) night stay, Patient # 7 reported to her mother " there were constant fist fights between the patients..she did not feel safe in this environment..."

Record review on 02-26-15 of the clinical record of Patient # 7 revealed she was 14 years old and admitted to the facility on 12-18-14. Patient # 7 was transferred from an acute care hospital, admitted for attempted suicide. Patient # 7 had a history of Bipolar Disorder and Depression.

Further review of the clinical record of Patient # 7 revealed a progress note dated 12-19-14 (2:45 p.m.) written by Licensed Professional Counselor Intern (LPCI) # 11 that read: "Therapist spoke with Mom by phone. Mom reports that the only reason pt. is still in the custody of this facility is because the admissions representative threatened to call CPS on her if she didn't admit her. Mom was irate on the phone...Mom repeatedly stated that her daughter is not safe here and is safer at home..."

Interview on 02-26-15 at 2:30 with LPCI # 11 she stated she remembered Patient # 7 and her mother well. She said Patient # 7's mother was very angry on the telephone on 12-19-14 and hung up on her. LPCI # 11 reported she was unable to obtain baseline information..she kept saying mamn....mamn....and then the mother hung up." The mother of Patient # 7 removed her daughter from the facility Against Medical Advice (AMA) on 12-20-14.

LPCI # 11 went on to say she did not document Patient # 7's mother's concerns about being threatened with CPS or her daughter not being safe in the facility. LPCI # 11 said she did not discuss or forward these concerns to her supervisor, nursing supervisor, or administration. She said " Looking back , I should have."

Record review on 02-26-15 of facility Grievance /Complaint Log 2014 failed to reveal a documented grievance concerning Patient # 7.

Review of facility policy titled" Patient Grievances/Complaints," dated 7/2014, read: "...Grievance: a patient complaint that cannot be resolved at the time of the complaint...Procedure 10. Upon receiving a complaint, the staff member shall request that the patient document it in writing. 11. if the patient declines to document the complaint, the staff member shall document complaint in writing. 12. The staff receiving the complaint should try to satisfactorily resolve the complaint ...14. If the staff member cannot resolve the complaint....it should be directed to the Nursing Supervisor or program therapist..25. Final resolution of all grievances will occur within 30 days.."