HospitalInspections.org

Based on review of facility policy, review of a Complaint and Grievance Log, medical record review, observation, and interview, the facility failed to adhere to the policy for resolution of a patient grievance and/or complaint for one patient (#1) of five sampled patients.

The findings included:

Review of facility Policy Number: C06-A dated February 2, 2007, revealed, "(Facility) has established a mechanism for receiving, acting upon, and responding to patients, families,, and visitors expressing concern for patient treatment and all areas of quality of care...The patient, family member...may inform the Hospital of a complaint or grievance verbally or in writing...If a complaint cannot be resolved timely...the staff member shall notify his/her supervisor and complete the "Angry Man" complaint form...The form is then forwarded to the Hospital's Director of Quality Management or Director of Clinical Services...shall notify the CEO (Chief Executive Officer when a grievance has been received and logged in the...Grievance database...Director of Quality Management 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 the complaint...Grievances and grievance resolution are reported to the Hospital Governing Board..." Continued review revealed, "...Patient/Family Report...Complaint/Grievance (complete front only) Abuse and/or Neglect (complete front & back)..."

Medical record review revealed the patient was admitted to the facility on April 23, 2012, with diagnoses including Chronic Pain Syndrome, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Medical record review of a Psychiatric Consult dated May 9, 2012, revealed, "...Reason for consult c/o (complains of) anxiety and depression...been requested for differential diagnosis and psychotherapeutic interventions for emotional, behavioral and cognitive issues...fully alerted to person, place, time, date and circumstances. Recall for remote and recent events is good..."

Review of a Complaint and Grievance Log provided by the Interim Chief Nursing Officer on May 14, 2012, revealed the most recent complaint logged was dated February 10, 2012, and no documentation regarding Patient #1.

Interview with Registered Nurse (RN) #2 on May 14, 2012, at 11:23 a.m., in an office, revealed Patient #1's daughter reported an allegation of physical abuse, and RN #2 stated, "...daughter rolled her eyes like don't worry about it...I did not fill out (a) complaint form."

Interview with a Quality Coordinator on May 14, 2012, at 12:10 p.m., in an office, revealed facility staff had failed to complete paperwork required by facility policy following an allegation of abuse regarding Patient #1.

Observation and interview with Patient #1 on May 14, 2012, at 1:27 p.m., revealed Patient #1 on a bed, no visible bruises/marks or symptoms of emotional distress, and Patient #1 stated, "...(Registered Nurse - RN #1) was mean to me. They got her out...was hateful talking to me...talked to me like I was stupid...She lifted my leg and put it on the bed and said, 'I don't want to be your nurse anyway.' My daughter told them (about allegation). This happened about the first week I was in here. (I) think it was intentional." Continued interview revealed there were no witnesses to the alleged events.

Interview with RN #1 on May 14, 2012, at 1:47 p.m. in unoccupied patient Room 436, revealed RN #1 was aware Patient #1 and the patient's family had concerns about the patient's care and RN #1 stated, "...(The) last Sunday I was working...heard (patient's) daughter complaining in general how we weren't checking on people...(The following day)...(Interim Chief Nursing Officer) pulled me aside and said the daughter said I hit (patient)...I was supposed to have pulled (patient's) leg...patient said it was me..." Continued interview revealed denial RN #1 hit or inappropriately treated Patient #1.

Interview with the Interim Chief Nursing Officer on May 14, 2012, at 1:55 p.m., in an office, revealed the facility did not investigate Patient #1's allegations.

Interview with the facility's Administrator on May 14, 2012, at 2:05 p.m., revealed she had no knowledge regarding the allegations and confirmed the facility failed to adhere to the provisions of the facility's Complaint and Grievance Policy for Patient #1.

C/O: #20747