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SELECT SPECIALTY HOSPITAL MILWAUKEE
PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES
Tag No.: A0122
Based on record review and interview, the facility failed to investigate complaints per policy in 1 of 1 complaint of alleged abuse (Patient #1).
Findings include:
Per review on 12/19/2016, facility policy "Complaint and Grievance Procedure" No. C06-A, dated 10/1/2016 states: "The Director of Quality Management and/or Chief Nursing Officer will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO. The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint."
Per review on 12/19/2016, facility policy "Abuse, Neglect" No. A02-A, dated 7/1/2012, states: "The DQM and CNO will investigate according to the processes outlined in the Complaint and Grievance policy. ...Any allegation of abuse or neglect by an employee must result in removal of the patient from potential of further abuse. Any employee involved in such an accusation, will be suspended with pay and instructed not to come to the hospital, until the investigation is completed and the matter resolved. The CEO or designee will begin the investigation...All investigations will be prompts and thorough. All allegations will be logged in the Lotus Notes Grievance log..."
On 11/9/2016 CEO M received a verbal complaint alleging abuse of Patient #1 by Certified Nursing Assistant (CNA) E. During an interview on 12/20/2016 at 9:00 AM, CEO M stated M spoke with the complainant and staff on 11/9/2016. A grievance report for the incident was filed on 11/18/2016, 9 days after receiving the verbal complaint. The report contained written statements from involved staff members dated 11/16/2016 through 11/18/2016. CEO M stated "I neglected to follow up with the charge nurse regarding filling out a complaint form...which led to the delay [in completing and documenting a full investigation.]"
On 12/19/2016 at 3:55 PM, when asked about the time lag between the allegation and initiating a full investigation, Director of Quality Management (DQM) B stated "I wasn't aware that the allegation suggested any type of abuse. Once I found out [on 11/16/2016] we started a formal grievance process." DQM B went on to state that all staff are expected to fill out the complaint form as soon as they become aware of a complaint. DQM B stated that in the event of allegations of abuse, the "CNO, CEO and DQM work together, we talk with the patient first, get statements from the staff and suspend the staff member."
During an interview on 12/19/2016 at 3:25 PM, CEO A stated A was aware that CEO M was addressing the complaint. Per A, it is the facility's policy to "immediately suspend staff member" if there are allegations of abuse. CEO M stated on 12/20/2016 at 9:00 AM "I removed the caregiver from patient care, I thought I was doing the right thing...I neglected to read all the way through the policy regarding suspending [the accused staff member]."