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Based on interview and record review, for two (Patient #1 & Patient #4) of ten sampled patients, the Hospital failed to ensure that a complaint was properly investigated and follow-up provided to the patient and/or responsible party.

Review of the Hospital's policy titled, The Management of Patient Compliments/Complaints and Reporting of Mistreatment Policy, revised 4/1/17, indicated that the Hospital should establish a prompt resolution of patient grievances and report abuse/mistreatment and/or serious issues relating to patient care. The procedure for resolution of a complaint/grievance that is unable to be resolved at the time they are received and/or require additional review and follow-up are forwarded to the Patient Advocate either by email or by calling.

The Patient Advocate will facilitate grievance investigation and resolution and liaise with the complainant specifically:
*Complete the Patient Grievance Investigation and Tracking Form.
*Within two business days of receipt of the grievance, the Advocate generates and forwards an acknowledgement letter to the complainant.
*The Patient Advocate identifies the nature of the complaint and contacts the appropriate Department Head to begin the resolution process. The Department Head receives, via email, a copy of the completed Patient Grievance investigation and Tracking Form and responds in writing within three business days of receipt.
*The Patient Advocate reviews the written response and determines if additional follow-up with other departments is necessary, and if so, the previous step is repeated.
*Once the investigation has been completed, the Patient Advocate composes a written communication about the hospital's decision to the complainant.
*Reasonable turnaround time for complaint resolution is 7 days.

1. For Patient #1, the Hospital failed to respond to a written event report regarding abuse and mistreatment during patient care.

Patient #1 was admitted to the hospital in 6/2016 with a diagnosis of leukoencephalopathy (a progressive disorder that mainly affects the brain and spinal cord (central nervous system) secondary to a drug overdose that has resulted in profound cognitive (the act or process of knowing, perceiving) impairment.

On 11/6/18, record review indicated that there was an interdisciplinary meeting with the Complainant, the Chief Executive Officer, Chief Nursing Officer, Director of Social Services and the Patient's Social Worker on 10/19/18. Review of the Complainant's care related concerns were discussed at this meeting including broken teeth due to force feeding, Certified Nursing Assistants (CNAs) laughing at the patient and bruises of unknown source.

On 10/22/18, The Social Worker wrote an Event Report regarding the complaints brought forward and the Director of Social Services reviewed it.

The Surveyor interviewed the Risk Manager on 11/6/18 at 8: 01 A.M., The Risk Manager said that she learned of the interdisciplinary meeting and complaints on 10/22/18 and began an investigation. The Risk Manager said the Patient Advocate position was vacated in June 2018 so the Hospital is delegating the Nurse Manager responsible for the Patient to perform the grievance/complaint investigation and follow up. The Risk Manager submitted a Non- SRE (Serious Reportable Event) to DPH Health Care Quality on 11/2/18. The Risk Manager said that the findings of the investigation were not shared with the Complainant.

On 11/7/18 at 8:19 A.M., The Risk Manager said the Patient Advocate would have handled a grievance/complaint if it wasn't manageable by the Nurse Manager responsible for the Patient. The Risk Manager said that, at this time, they don't have a good system to follow up on complaints due to the vacant Patient Advocate position.

2. For Patient #4, the Hospital failed to complete an investigation and respond to a written Event Report regarding patient mistreatment, employees speaking in foreign language while providing care and misappropriation of patient personal property.

Patient #4 was admitted to the Hospital in 8/2018 with diagnoses including chronic respiratory failure with hypoxia (low oxygen levels) and post-traumatic stress disorder.

On 11/8/18, record review indicated that the Social Worker wrote a progress note on 10/17/18 indicating that Patient #4 was concerned due to an interaction with a staff member.

The Surveyor interviewed the Social Worker on 11/8/18 at 1:45 P.M. The Social Worker said that Patient #4 complained that staff members were mimicking the Patient and speaking in a different language while caring for the Patient. The Patient further complained of missing clothing, body wash and lotions brought in by family members.

Review of the Event Report, written on 10/17/18 by the Social Worker, who presented it to the Director of Social Services, indicated that the Social Worker and Director of Social Services forwarded the written grievance information and recommendations to the Nurse Manager to follow up. There is no further information in the Patient record regarding the grievance or follow-up to the Patient.

The Surveyor interviewed the Risk Manager on 11/9/18 at 9:27 A.M. The Risk Manager said that the Nurse Manager saw the patient and addressed the concerns. There was no documentation that the grievance was investigated or was followed up on by the Nurse Manager.

The Surveyor interviewed the Director of Social Services on 11/9/18 at 9:36 A.M. The Director of Social Services said that the Nurse Manager was recommended to have weekly meetings with the Patient, Family and the Social Worker, but follow through has been inconsistent.

As of 11/9/18 there were no formal written resolutions provided to address Patient #1's or Patient #4's complaint.

Based on interview and record review the Hospital's Quality Assessment and Performance Improvement Program failed to ensure that services furnished under contract were maintained and monitored.

Findings include:

The Surveyors interviewed the Risk Manager on 11/7/18 at 8:15 A.M. The Risk Manager said that the Hospital's Respiratory Therapists were a contracted service. The Surveyors requested the contract information and employee records for Respiratory Therapist #1 and Respiratory Therapist #2. The Risk Manager said that the Respiratory Therapy Company keeps their own records on site. The Risk Manager said that the Respiratory Therapy Company maintains their own records and employee competencies and that she did not know who in the Hospital was responsible for maintaining competencies of contracted employees.

The Surveyors interviewed the contracted Respiratory Therapy Manager on 11/7/18, at 10:40 A.M. The contracted Respiratory Therapy Manager said that she is responsible for keeping the contracted Respiratory Therapist employee records. The contracted Respiratory Therapy Manager provided the Surveyors with Respiratory Therapist #1 and Respiratory Therapist #2's employee records. The contracted Respiratory Therapy Manager said that she was responsible to assure that the employee's were licensed and completed the hospital competencies. The contracted Respiratory Therapy Manager said she was unaware of any hospital staff that checked the competencies.

The Surveyors interviewed the Hospital's Chief Executive Officer (CEO) on 11/8/18 at 2:00 P.M. The CEO said that no one from the Hospital was verifying that the contracted service's employees were licensed or completed orientation. The CEO said that the Respiratory Therapy Company was a trusted longtime contracted service, but that did not excuse the fact that no one in the Hospital has checked or verified that the Respiratory Therapists were licensed and in good standing to practice.