HospitalInspections.org

Based on document review and interview, it was revealed the facility failed to review and resolve a patient grievance for one (1) of ten (10) patients, patient 1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Handling of Patient Complaint / Grievances" effective date 6/13/24. The policy has a section titled "Definitions" which states, in part, "As referenced in The State Operations Manual A-0118 "A 'patient grievance' is a formal or informal written or verbal complaint made to the hospital by a patient or the patient's representative, facility employee or other individual on behalf of any patient regarding the patient's care." The policy has a section titled "Purpose" which states, in part, "The intent is to address patient complaints and grievances regarding patient care and services in a timely and responsive manner."

A document titled "MMBH Grievance Log (April)" was reviewed. An entry dated 4/8/25 indicates that patient 1 filed the following complaint, "Patient states, 'We need to have treatment team with all team members present, in person come to meet with us in person Zoom & remote meetings are for business, not Department of Health and Human Resources (DHHR) or hospital come to patient. [Staff 4] does not see his patients every week." A section of this entry titled "Notes" states, "The Nurse Manager spoke with the Medical Director, who stated the meetings would always be virtual due to time and scheduling. This was explained to the patient and [he/she] was not satisfied with the response. This resolution was not satisfactory with the patient and [he/she] declined/refused to sign the grievance form. The patient wished to appeal this resolution to the Mental Health Ombudsman, who approved the complaint appeal."

An interview was conducted with staff 2 and staff 3 on 4/21/25 at 2:09 p.m. Staff 2 was asked about patient 1's current treatment. Staff 2 stated, "We recently had a clinical case conference on [him/her]. We've got a game plan for [him/her] going forward, focusing on re-looking at guardianship." Staff 2 was asked if he/she was aware of patient 1 requesting that his/her treatment team meetings be done face-to-face. Staff 2 stated, "It's not really the standard here but if it is needed. I was not aware of a face-to-face request." It should be noted that Staff 2 is the medical director who replied to the patients grievance.

A telephone interview was conducted with staff 4 on 4/22/25 at 2:09 p.m. Staff 4 was asked if he/she was aware that patient 1 had filed a complaint asking to have treatment team meetings face-to-face rather than virtually. Staff 4 stated, "I was not aware of that."

An interview was conducted with staff 9 on 4/22/25 at 2:45 p.m. Staff 9 was asked about his/her response to a complaint from patient 1. Staff 9 stated, "We have a monthly meeting with nurse managers and [staff 2] to bring up concerns or issues that we're having. Some patients had brought up that they didn't like the virtual meetings because it was like talking to a machine. The response to the complaint was based on a conversation that had happened at a meeting months earlier. I guess I could've written the response more clearly. I think it would be wonderful to do it in person, I used to do the treatment team meetings in person."

An interview was conducted with staff 1 on 4/23/25 at 11:20 a.m. Staff 1 was asked about moving to face-to-face treatment team meetings. Staff 1 stated, "I like the idea of face-to-face. There may be times when we have eighteen (18) people, and we'll have trouble placing them all." Staff 1 was asked about the handling of patient 1's complaint about this issue. Staff 1 stated, "I have already sent out an email to leadership stating that we need to do a better job of communicating when it comes to complaints."