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HARPER UNIVERSITY HOSPITAL
PATIENT RIGHTS: GRIEVANCES
Tag No.: A0118
On 11/14/10 the facility policy titled "Patient & Family Grievances and Complaints Feedback Manager" (3 HUH HWH CLN 8033) was reviewed. On page 2, #4 the policy states: "All complaints related to quality of patient care and service issues that are not resolved at the time of the complaint are entered into SRM Feedback Manager by staff in the receiving department for tracking and reporting."
On 11/14/10 at approximately 1230, patient #3 was interviewed by phone. The patient stated that he had voiced complaints regarding his care to nurses and Security staff members. On 11/14/10 from 1330-1500 patient #3's clinical record was reviewed with the Director of Quality & Compliance (staff #3). Staff #3 verified that the patient's record contained complaints to nursing on 11/30/10 and 12/1/10 and to Security on 11/27/10, that his rights to privacy and protection from abuse had been violated. Staff #3 also verified that there was no documentation to indicate that the facility followed policy by tracking and reporting patient #3's complaints per the SRM process.
On 11/14/10 at approximately 1335 the Director of Security Operations (staff #5) was asked why he had not reported patient #3's complaints into the SRM system. Staff #5 stated that he was unaware of a reporting requirement unless a patient sustained injury.
PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Tag No.: A0145
On 12/14/10 the facility policy titled "Assessing and Reporting Suspected Victims of Abuse/Neglect/Elderly/Vulnerable Person (1 CLN 018) was reviewed. The policy states: "All patients are assessed as potential victims of violence."
On 12/14/10 from 1330-1500 review of patient #3's clinical record revealed allegations of abuse by the patient on 11/27/10, 11/30/10 and 12/1/10. On 11/30/10 a Clinical Nurse Practitioner (staff #7) documented that patient #3 was alert and oriented x 3 (in 3 spheres) but also noted a diagnosis of Psychosis and a history of making paranoid allegations of injury. There was no documentation to indicate that the facility had fully investigated the patient's mental status and allegations of abuse. These findings were verified by the Director of Quality & Compliance (staff #3).