The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|DOVER BEHAVIORAL HEALTH SYSTEM||725 HORSEPOND ROAD DOVER, DE 19901||Sept. 30, 2020|
|VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION||Tag No: A0123|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, document review and staff interview, it was determined that for 1 of 4 grievance files reviewed (Patient #1), the hospital failed to provide written notice of the results of the grievance decision to the complainant. Findings included:
The hospital policy entitled "Patient and Family Grievances/The Role of the Patient Advocate" stated, "...A written complaint is always considered a grievance...an Email...is considered 'written'...patient advocate will provide written notification to...patient and/or family member who made a grievance within 7 working days...if the investigation is not or will not be completed within 7 days, the hospital will follow-up with a written response on day 7 of the date of the complaint..."
A. Review of Patient #1's grievance documentation on 9/29/20 revealed the following:
- the hospital was in receipt of a written complaint email dated 1/29/20 at 10:14 AM from the patient's representative (Complainant #1) to Social Worker A
- Complainant #1 expressed concerns related to inappropriate relationship, possible abuse and unauthorized visitation issues identified during the then [AGE] year old patient's hospitalization
- written response to Complainant #1 by Social Worker A on 1/29/20 at 10:55 AM stated, "I have forwarded your concerns to the Director of Nursing, the Nursing Manager for the adolescent unit, my clinical director, as well as the patient advocate".
- no evidence of any other correspondence with Complainant #1 after 1/29/20
B. Interview with Social Worker A on 9/29/20 between 11:40 AM and 11:55 AM revealed:
- received Complainant #1's complaint via email
- email forwarded to designated department heads for each identified complaint issue
- advised Complainant #1 of forwarding complaint to department heads
No evidence the hospital provided the patient/patient representative (Complainant #1) with written results of the grievance.
This finding was confirmed by Director of Risk Management A on 9/30/20 at 12:04 PM.
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observation, document review and staff interview, it was determined that for 3 of 12 hospital locations observed on 9/29/20, the hospital failed to ensure that personnel (Employee #'s 1, 2, 3, 4, 5, 6, 7 and 8) adhered to infection control measures. Findings included:
The hospital signage at the screening entrance area stated, "All staff must wear a mask when in the facility...when in patient care areas, staff must wear a surgical ear loop mask...when in non-patient care areas, staff can wear fabric or surgical mask."
The hospital policy entitled "PPE (Personal Protective Equipment)" stated, "...a mask shall be worn in any situation...to prevent the spread of micro-organism from...staff of patient to others who are susceptible."
The hospital competency entitled "Dover Behavioral Health Competency" stated, "...mask or respirator...secure ties or elastic bands at middle of head and neck...fit snug to face and below chin." Review of employee records revealed that between 4/9 and 9/29/20, this competency was completed by Employee #'s 1, 2, 3, 4, 5, 6, 7 and 8.
During a tour with Infection Prevention Control Nurse A on 9/29/20, the following hospital staff were observed not wearing masks:
A. Medical Records Department
- Employee #'s 1 and 2 (between 1:22 PM and 1:25 PM)
B. Pharmacy Department
- Employee #3 at 1:27 PM
- Employee #'s 4 and 5 at 1:40 PM
C. Dietary Food Preparation area
- Employee #'s 6, 7 and 8 (between 1:50 PM and 1:55 PM)
These findings were observed and confirmed by Infection Prevention Control Nurse A and Director of Nursing A on 9/29/20 at 2:10 PM.