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Based on Record Review and interview the facility's Governing Body failed to ensure that it had an effective grievance process. In addition, the facility Governing Body failed to ensure that appropriate review of grievances was conducted. These deficient practices had the likelihood to create an environment where a person's rights could be violated. Citing 2 ( #1, and #2) of 2 grievances that were not on the greviance log. Also citing 3 (#6, #15 and #16) of 8 grievances (#4, #6, #8, #9, #10, # 14 #15, #16) listed on the grievance log.

Findings:

Review of the grievance log revealed there was no evidence that patients # 1 and # 2 grievances were listed on the grievance log. Further review of the log from January 1, 2017 through the date of the survey revealed that there were 14 complaints/grievance's that were filed from 01/01/2017 through 6/23/2017. Further review revealed that grievance #6 occurred on 01/09/2017; grievance#15 occurred on 05/15/2016 and grievance #16 occurred on 05/26/2017. There was no evidence the grievances had been investigated and that a final disposition letter was sent to the person filing the grievance.


Review of patient #1's medical record for 04/27/2016 at 22:08 confirmed that nurse #5 documented on arrival the patient was "A&O x 2" which means alert and orientated to person and place. The nurse also documented the patient "speaks fluent English, denies tobacco use. Patient uses alcohol occasionally and denies using street drugs."

In an interview on 06/26/2017 at 10:00 a.m., staff #7 and #8 confirmed they had received a telephone call about this complaint. Staff #7 stated she called the complainant and was told that the staff had violated the patient's privacy. Staff #7 stated she informed staff #2 about the complaint. In an interview with Staff #2 at approximately 11:30 a.m. by telephone, she confirmed patient #1 had been brought into the emergency department on 04/27/2017 by EMS. She stated that staff #5 and #6 were on duty the night of his arrival. She also confirmed by reading the chart that the patient was oriented to person and place. In addition she confirmed patient #1 was able to give his name on check in to the emergency department. In a telephone interview with staff #5 on 10/26/2017 at 11:00 a.m. she stated she was the nurse who took the patient to the CT scan. She stated he was alert to person and place during the CT scan and was asking to call his mother. She stated the patient was cleared by the physician to be released into police custody. Staff #5 stated that Charge Nurse #6 was the staff member who went through the patients backpack and notified the police. In an interview with staff #6 by telephone on 06/26/2017 at approximately 12:30 p.m. he confirmed he did go through the patient's backpack and found a packet that looked like cocaine or methamphetamine. When asked if they knew the patient's name on arrival he confirmed they knew his name. When asked why he went through the patient's personal belongings he stated they had several patients in the past that had given them the wrong name, so he was just trying to verify his name. In addition Staff #6 confirmed that he "called the police and they came and took the patient to jail." He stated the physician had cleared the patient for discharge.

Review of the facility policy titled "Patient Possession of Illegal Drugs or Drug Paraphernalia" approved by the governing body 2.2 states "Facility personnel may not search a patient for illegal drugs unless the patient's permission is obtained."

Review of the complaint log revealed the name of patient #2 was not on the complaint log. In an interview with staff #2 and #3 at approximately 10:30 a.m. they both confirmed they were aware of the patient's claim that she was assaulted. Staff #3 stated the patient had called the police and they came to the hospital and investigated the complaint and they decided there was no assault. Staff # 2 confirmed he had also investigated the complaint and did not find any evidence that the patient was assaulted. Staff #3 stated he did not put the complaint on the complaint log and did not send the patient the investigative follow up to the complaint.

Based on record review and interview, the facility's Governing Body failed to ensure it had an effective grievance process. In addition the facility's Governing Body failed to ensure that appropriate review of grievances was conducted and a letter of findings sent to the complainant. These deficient practices had the likelihood to create an environment where a person's rights could be violated. Citing (#1, and #2) of 2 grievances that were not on the log. Also citing 3 (#6, #15 and #16) of 8 grievances (#4, #6, #8, #9, #10, # 14 #15, #16) listed on the log.

Findings:

Review of the grievance log revealed there was no evidence that patients # 1 and # 2 grievances were listed on the grievance log. Further review of the log revealed from January 1, 2017 through the date of the survey there were 14 complaints/grievances that were filed from 01/01/2017 through 6/23/2017. Further review revealed that complaint #6 occurred on 01/09/2017, complaint #15 occurred on 05/15/2017, and complaint#16 occurred on 05/26/2017. There was no evidence the grievances had been investigated or that a final disposition letter was sent to the person filing the grievance.

Based on record review and interview, the facility's Governing Body failed to ensure 1 of 1(#1) patient's personal privacy.


Findings:



Review of patient # 1's medical record for 04/27/2016 at 22:08 confirmed that nurse #5 documented on arrival the patient was "A&O x 2" which means alert and orientated to person and place. The nurse also documented the patient "speaks fluent English, denies tobacco use. Patient uses alcohol occasionally and denies using street drugs."


In an interview on 06/26/2017 at 10:00 a.m., staff #7 and #8 confirmed they had received a telephone call about this complaint. Staff #7 stated she called the complainant and was told that the staff had violated the patient's privacy. Staff #7 stated she informed staff #2 about the complaint. In an interview with Staff #2 at approximately 11:30 a.m. by telephone, she confirmed patient #1 had been brought into the emergency department on 04/27/2017 by EMS. She stated that staff #5 and #6 were on duty the night of his arrival. She also confirmed by reading the chart that the patient was oriented to person and place. In addition she confirmed patient #1 was able to give his name on check in to the emergency department. In a telephone interview with staff #5 on 10/26/2017 at 11:00 a.m. she stated she was the nurse who took the patient to the CT scan. She stated he was alert to person and place during the CT scan and was asking to call his mother. She stated the patient was cleared by the physician to be released into police custody. Staff #5 stated that Charge Nurse #6 was the staff member who went through the patients backpack and notified the police. In an interview with staff #6 by telephone on 06/26/2017 at approximately 12:30 p.m. he confirmed he did go through the patient's backpack and found a packet that looked like cocaine or methamphetamine. When asked if they knew the patient's name on arrival he confirmed they knew his name. When asked why he went through the patient's personal belongings he stated they had several patients in the past that had given them the wrong name, so he was just trying to verify his name. In addition Staff #6 confirmed that he "called the police and they came and took the patient to jail." He stated the physician had cleared the patient for discharge.




Review of the facility policy titled "Patient Possession of Illegal Drugs or Drug Paraphernalia" approved by the governing body 2.2 states "Facility personnel may not search a patient for illegal drugs unless the patient's permission is obtained."