HospitalInspections.org

Based on interview and record review the Governing Body failed to ensure that the Administrator of the hospital was not the Administrator simultaneously at other licensed facilities. This failed practice was evidenced by the Administrator being designated as the Interim Administrator for the hospital while simultaneously Administrator at other licensed facilities.

Findings:
A review of the organizational chart for the hospital, as provided by S1ADM as the most current, indicated that S1ADM was the Interim Administrator for the Hospital.

In an interview on 04/07/14 at 1:00 p.m. with S1ADM, she indicated that the prior administrator resigned in October 2013 and that she was designated as the Interim Administrator. S1ADM indicated that she was the Administrator for another licensed facility in the state. S1ADM further indicated that she was also the Administrator for 2 other licensed facilities in another state. S1ADM indicated that she divided her time each month at the 4 different locations and S2DON handled any situations on the days she (S1ADM) was not available.

Based on interview and record reviews the hospital failed to ensure that upon the resolution of a patient's grievance that the hospital provided a written notice to the patient or patient's family that contained a hospital contact person, the investigative steps taken by the hospital to address the grievance, the results of the grievance process and the date the grievance investigation was completed. This failed practice was evidenced by no documented evidence of a written notice to the patient or to the patient's family in the hospital's grievance reports for 2 of 2 grievance reports reviewed for completeness out of a total of 5 grievances reported in 2014.

Findings:
A review of the hospital's grievance log for 2014 revealed Patient #3's mother had filed a grievance on 2/20/14 and 2/28/14 regarding nursing services.

A review of the grievance investigative reports regarding Patient #3, provided by S1ADM as completed reports, revealed each grievance was reported to a staff member and was referred to Administration on the day the grievance was reported and an investigation was initiated. The grievance reports further revealed that recommendations and actions were taken and each grievance result was verbally addressed with Patient #3 and Patient #3's mother by Administration. A further review of the grievance reports revealed no evidence that the hospital provided a written notice of the grievance results to Patient #3 or to Patient #3's mother.

In an interview on 04/08/14 at 11:30 a.m. with S1ADM she was asked if the hospital provided a written notice of the grievance results to Patient #3 or to Patient #3's mother. S1ADM indicated that the hospital had not been providing written notices to the patients or their families
if the hospital had provided a verbal response to the patient or the patient's family.