HospitalInspections.org

Based on observation, staff interview, and document review, the acute care hospital's administrative staff failed to provide each patient all information required to file a complaint in 2 of 2 observed inpatient care areas (Behavioral Health Lower Level, Behavioral Health Ground Level). Failure of the hospital staff to provide required information may result in patient's inability to report complaints related to abuse, significant mental anguish, physical pain, or injury to the state agency. The hospital identified a census of 71 inpatients on entrance.

Findings include:

1. Observations on 5/13/19 at 3:40 PM during a tour of the Ground Level Behavioral Health inpatient unit revealed the hospital staff posted information informing the patients of their rights in the Group Room of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals (the state agency responsible for enforcing federal hospital regulations and determining if hospital staff abused patients in hospitals).

2. Observations on 5/13/19 at 3:45 PM during a tour of the Lower Level Behavioral Health inpatient unit, revealed the hospital staff posted information informing patients of their rights in the hall of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals.

3. During an interview at the time of the tour, Behavioral Health Nursing Director acknowledged posted patient rights' information lacked the complaint number for the Department of Inspections & Appeals.

4. Review of the policy "Patient Rights and Responsibilities," revised 03/2017, revealed the hospital staff failed to list the complaint number for the Department of Inspections & Appeals when listing the resources available for patients to report concerns about the hospital.

5. Review of the booklet "Patient Handbok and Clinic Directory," revealed the document lacked the phone number to file a complaint with the Department of Inspections and Appeals.

6. During an interview on 5/14/2019 at 8:10 AM, Chief Nursing Officer disclosed the hospital had 15 Patient Rights posters located throughout the hospital. The Chief Nursing Officer acknowledged the hospital staff did not post or distribute the DIA complaint number to their patients.