HospitalInspections.org

Based on staff interviews and facility document reviews it was determined the facility's staff failed to ensure patients were informed of their right to lodge a grievance with the State agency and failed to provide the phone number and address for lodging a grievance with the State agency.

The findings were:

The facility's management team were provided a list of information they would need to make available to the survey team, during the survey's entrance conference on the morning hours of 02/23/17. That list included a request to make available all information given to patients and/or their representatives in writing upon admission, as well as the policies and procedures for Patient's Rights.

The surveyor reviewed documents provided by the facility's management team on 02/28/17 at 10:45 AM. Those documents included a binder titled, "My Health Journal" which the facility's CEO (Chief Executive Officer) stated to be the information provided to all patients upon admission. The "Patient Rights and Responsibilities" were provided on pages 21 through 24 of the binder and included a section titled "Complaints/concerns and questions." Information found in that section included a description that any concerns or complaints should be reported to "hospital staff" and that "You may also contact The Joint Commission, a hospital accreditation organization" and provided that contact information. The aforementioned binder as well as the "Patient Rights and Responsibilities" document, failed to inform patients and/or their representatives of their right to lodge a grievance/complaint with the State agency, regardless of whether they had first used the hospital's grievance process. Those same documents failed to include any mention of the State agency's phone number and address where grievances/complaints could be received.

The survey team met with the CEO, the Director of Case Management, and the Director of Quality and Risk on 02/28/17 at 12:55 PM to discuss the surveyor's findings after reviewing the binder, "My Health Journal" which included the "Patient Rights and Responsibilities" document. The facility's aforementioned management team members were informed the documents reviewed failed to provide evidence the patients and/or their representatives were informed of their right to lodge a grievance/complaint with the State agency, nor were they provided the contact information (phone number and address) of the State agency. The Director of Case Management also reviewed the aforementioned binder including the Patient's Rights and Responsibilities document and stated, "it's not there." The surveyor team again asked for the facility's policy and procedure related to patient's rights. The Director of Quality and Risk Management stated he/she would look into the surveyor's questions and get back to the survey team.

The survey team reviewed the facility's policy titled, "Rights and Responsibilities of Patients" on the afternoon of 02/28/17. The policy directed that each patient "shall be informed by the Admissions Office of these rights and responsibilities upon admission as an inpatient......" The Policy failed to provide guidance or direction to inform patients of their right to lodge a grievance with the State agency and failed to provide the phone number and address for lodging a grievance with the State agency.

The survey team met with the facility's management team for an end of day review and discussion on 02/28/17 at 5:40 PM. During that discussion, the management team was asked if there was any additional information to be provided regarding the patients being informed of their right to lodge a grievance/complaint with the State agency. The CEO acknowledged there was no additional information or evidence to be provided and stated, "It's not in there." The CEO stated the aforementioned information not having been included in the admission information was an "oversight" and that it would be corrected.