HospitalInspections.org

Based on review of facility policies and procedures, review of medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that patient complaints were recorded and investigated for two of five applicable medical records reviewed (MR2 and MR4).

Findings include:

A review on February 5, 2010, of Sunbury Community Hospital policy "Patient Rights" last reviewed September 2009, revealed: "Policy: ... 12. The patient has the right to voice opinions, recommendations and grievances related to policies and services offered on the unit. ..."

A review on February 5, 2010, of Sunbury Community Hospital policy "Lodging / Resolving Formal Grievances and Investigating Alleged Violations of Patient Rights" last reviewed September 2009, revealed: "The purpose of this policy is to develop a process whereby patients can ... resolve grievances or violations of their rights. ... Article VII - Grievance and Appeal Procedures: to ensure that these rights are safeguarded and that disputes concerning their rights and others are resolved promptly and fairly. ... Grievance procedure: (a) Any patient ... may initiate a complaint orally or in writing. The compliant shall be presented as soon as possible to the treatment team leader or other appropriate professional. ... (c) The treatment team leader, administrative supervisor, or their designees receiving the complaint shall investigate the complaint and make every effort to resolve it.

1) Review of Sunbury Community Hospital's Behavior Health Unit Grievance Log on February 5, 2010, from May 15, 2009, to October 22, 2009, revealed that MR2 filed an oral grievance on October 22, 2009. Further review revealed that the status of MR2's complaint continues to be pending. There was no documented evidence that the facility recorded the nature of MR2's oral grievance or that the grievance investigation was completed.

2) Review of MR4 on February 5, 2010 revealed that the facility admitted MR4 on April 30, 2009, and discharged MR4 on June 15, 2009. Further review of MR4 revealed that the patient made several oral grievances with Sunbury Community Hospital's Behavior Health Unit staff during this time. There was no documented evidence that the facility recorded any of MR4's oral grievances on the Behavior Health Unit Grievance Log or that the complaint investigations were completed.

3) Interview with EMP1 and EMP2 on February 5, 2010 at 3:00 PM confirmed that MR2 and MR4 lodged oral complaints with the facility. Further interview with EMP1 revealed that all oral grievances from patients are put into writing. EMP1 confirmed that MR2 and MR4's oral grievances were not put into writing and that the investigations of MR2 and MR4's grievances were not completed.

Based on review of facility policies and procedures, review of medical records (MR), and staff interview (EMP), it was determined that the facility failed provide the patient with written notice of its decision that contained the name of the contact person, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance process, and the date of completion for five of five applicable medical records reviewed (MR1, MR2, MR3, MR4 and MR5).

Findings include:

A review on February 5, 2010, of Sunbury Community Hospital policy "Patient Rights" last reviewed September 2009, revealed: "Policy: ... 12. The patient has the right to voice opinions, recommendations and grievances related to policies and services offered on the unit. ..."

A review on February 5, 2010, of Sunbury Community Hospital policy "Lodging / Resolving Formal Grievances and Investigating Alleged Violations of Patient Rights" last reviewed September 2009, revealed: "The purpose of this policy is to develop a process whereby patients can ... resolve grievances or violations of their rights. ... Policy: ... A. Have knowledge of, and access to, a formal procedure for lodging grievances or complaints ... so that such grievances may be acknowledged and resolved to the satisfaction ... D. Resolution - When a patient's grievance reaches resolution a copy of the process and the results will be placed in the patient's medical record. ... Article VII - Grievance and Appeal Procedures: ... (c) The treatment team leader, administrative supervisor, or their designees receiving the complaint shall investigate the complaint and make every effort to resolve it. Based upon this investigation, a decision shall be rendered in writing as son as possible but within 48 hours ... d) The patient shall be given a copy of the complaint and final decision and copy shall be filed in the patient's record. ..."

1) Review on February 5, 2010 revealed documentation that Sunbury Community Hospital Behavior Health Unit staff were aware of grievances filed by MR1, MR2, MR3, MR4 and MR5. There was no documented evidence that the facility completed an investigation of the grievances. Further review of MR1, MR2, MR3, MR4 and MR5's revealed no documented evidence that the that the facility placed a copy of the complaint, final decision or resolution in the medical record.

2) Interview with EMP1 and EMP2 on February 5, 2010, at 4:00 PM confirmed that the Behavior Health Unit staff were aware of the grievances filed by MR1, MR2, MR3, MR4 and MR5's. EMP1 also confirmed that the facility did not place a copy of the complaint, final decision or resolution in MR1, MR2, MR3, MR4 and MR5.