HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of ten (10) medical records review, the facility failed to follow their process for grievance resolution.

Findings:

A review of the facility's policy titled "Response to Allegations of Assault against a Patient (Including Sexual Assault and/or Misconduct)," Revised in June 2017, revealed investigation guidelines:
(a) Initial Steps:
i. Risk Management and Patient Safety will conduct an evaluation of the allegation(s) and direct the investigation with the assistance of other departments ...
(b) Follow-up Steps:
i. The Leadership Representative will determine how investigative interviews will be conducted and who will perform them ...
(c) A report of the investigation will be made by the Leadership Representative. The report will include:
i. A summary of the investigation findings, including a list of all interviews and any conclusions and recommendations that were agreed upon by the involved departments ...
ii. Supporting documentation described above ...
(d) Risk Management and Patient Safety will maintain the report and ensure that the
appropriate parties are notified of the findings of the investigation report ..."

A review of the grievance report revealed that patient #1 complained on 2/20/2024 and 2/26/2024 that they were sexually assaulted by hospital staff during their admission in December 2023. The facility initiated an investigation on 2/21/2024.

The facility documented the status of the investigation as "Resolved," and the Date closed/Date of Resolution and Letter to the complainant was dated 2/27/2024.
The response letter to the patient indicated that the facility could not validate the patient's complaint.

There was no documentation of the investigation findings, including a list of all interviews and any conclusions as per the facility's policy "Response to Allegations of Assault against a Patient (Including Sexual Assault and/or Misconduct)."

On 06/12/2024, at approximately 12:00 p.m., during an interview with Staff B (Director of Patient Services), they provided a list of staff members interviewed and confirmed that the interviews were not documented.

During an interview with Staff G, Chief Nursing Officer, on 6/13/2024 at approximately 1:10 p.m., they acknowledged the lack of a summary of investigation findings, including staff interviews.

These findings were brought to the attention of the facility's administrative personnel, Staff D (MD., CMO) and Staff G (Chief Nursing Officer), during the survey exit conference on 06/13/2024 at about 4:00 p.m.