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Based on review of facility documents, interviews with staff and a patient's family member, it was determined that the facility failed to conduct a timely and comprehensive investigation of a complaint presented by the family of the patient identified in MR1.

Findings include:

Review of facility policy #8 "Patient and Customer Complaint or Grievance" states that,
1.) "prompt and effective resolution is the goal for resolving patient complaints, regardless of whether it is a minor complaint or a serious grievance."
2.) "Hospital CEO or designee must initiate an investigation, in coordination with hospital Risk Management if needed, and determine the necessity for completing an Event Report (RM-600) and/or a Root Cause Analysis (as defined in RM-691)."
3.) "The hospital should make sure that it is responding to the substance of each grievance, while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance."
4.) "All grievances must be recorded in the hospital grievance log."

The facility failed to follow their own policy and provide a prompt and effective resolution to patient and family member when complaint was made. The patient's family member stated, " ..........., they called the sending facility, but they didn't have them, so I was told we must not have given them to the facility".
The facility failed to follow their policy and initiate an investigation. During an interview with EMP 2 on May 23, 2019, it was stated that an investigation was not conducted because "the patient's husband never made a formal written complaint to the facility". According to patient's family member upon admission he was asked to "surrender the patient's home medications to the facility". Upon discharge, the patient's family member realized that all the medications were not returned so they questioned this and were told the "the facility never received them". There is no documented evidence that a formal investigation was conducted by the facility.

During interview with EMP 2, on May 29, 2019, the staff member confirmed that the facility failed to provide evidence that it had responded to the substance of the grievance; no documentation was produced by the facility to show that the facility responded to the grievance by investigating to determine if there were systematic problems; and failed to enter the family's complaint on the grievance log.

Based on review of facility documents, medical records, and staff interviews, there was no evidence of accurately completed documentation for patient's personal belongings at the time of admission to the facility. (MR1)

Findings include:

Review of facility documents revealed the facility did not have a written policy or procedure for staff to follow when admitting a patient.

Review of MR 1 on May 22, 2019, at 10:00 a.m., revealed a page which contained boxes to be checked by the user at time of patient admission to account for patient's personal belongings. The listed included but was not limited to clothing, shoes, dentures, glasses, medications, etc. No boxes were checked on the page.

Interview with EMP1 on May 22, 2019, at 10:00 a.m., about MR 1 confirmed that no boxes were checked on the page, EMP1 stated "there is no box to check for no belongings; so, if the form is empty it is assumed the patient did not arrive with any belongings."

Interview with EMP 4 and EMP 5 on May 22, 2019, at 10:56 a.m. and 11:20 a.m. revealed that there is no specific step by step process to be followed when a patient is admitted. Both staff members were unsure about what to do when checking in a patient's belongings, specifically patient's medications.

Based on a review of medical records, facility documents and interview with staff the facility failed to follow its own policy regarding patient's own medications and minimizing scheduled drug diversions.

Findings include:

Review of facility policy #230 "Patient's Own Medications- 1. On presentation to the Hospital" states "following their use for medication history process, Patient own med should be sent home with the patient's caregiver unless ordered by a physician for in hospital administration."

An interview with EMP 1 on May 29, 2019, at 2:45 p.m., was conducted to clarify this policy becuase the patient's own medications were not ordered by a physician for in hospital administration and were kept within the building until patient's discharge. EMP1 stated "I do not know why the medications were kept here."

Based on the review of medical records, facility documents, and interview with staff, the facility failed to report a suspected drug diversion to the Bureau of Drug Control of the Office of Attorney General (DEA).

Findings include:

According to the complainant, they were asked at the time of admission to give to the faciltiy any current medications that they had brought with them. At the time of discharge, the complainant indicated that several of those medications were not returned to them one of which was oxycodone.

A review of MR 1, hospital complaint logs, and staff interviews revealed no evidence that the allegation of missing narcotics was reported by the facility to DEA. Interview with EMP 2 on May 23, 2019, at 3:15 p.m., stated " we never had those medications in the first place, so there was no need to report a drug diversion for drugs we didn't have." The request was made several times to the facility to file a report; as of May 29, 2019, no report was filed.