HospitalInspections.org

Based on observation, interview and record review facility failed to inform 3 patients (P-7, 9 and 10) of 3 patients interviewed, about internal grievance process, including whom and how to contact to file a grievance, resulting in lack of patients' understanding of facility's grievance process and potential for negative outcomes. Findings include:

Upon entrance to facility on 03/19/24 at 0940 lobby was observed for patient rights and grievances/complaints signage. Posted information was observed to have incorrect name of the patient rights advocate.
On 3/19/24 at 1000 during initial tour of the facility patient rights postings were observed to have incorrect name of the patient rights advocate on unit 1C and 2D. Complaint/grievance forms were available.

Interviews were conducted with staff and patients during tour of the facility on 03/19/24 at 1000. P-7 was questioned if she had witnessed verbal or physical abuse on the unit. P-7 stated that she had not and that she felt safe. P-7 was next asked how she would report it if she had seen abuse. P-7 replied that she did not know how to report abuse. P-7 was standing approximately 10 feet away from the 'recipient rights forms' box, which was mounted on the wall behind her. Another patient standing nearby overheard the conversation and quickly retrieved a form and handed it to the patient. P-7 stated, "I didn't know those were there or that how we could make reports."

On 3/19/24 at 1300 interview was conducted with P-10. Patient stated that he was in a facility for a week and was anticipating a discharge in a day or two. P-10 was asked if he knew how to file/submit a grievance or complaint with a facility in case he had any issues or concerns to address. Patient stated 'no'. When asked if he saw a silver-like metal box with the complaint forms across from the unit entrance, he said "oh, nice to know, now I know how".

On 3/19/24 at 1315 P-9 was interviewed. Patient said that he was admitted to facility over the weekend, and this is his 3rd day here. Patient was asked about grievance submission/filing process and if he is familiar with it. P-9 said he did not know how to file a grievance with the facility. When asked about the metal box with grievance forms available across the unit's entrance, P-9 said that he did not know that it was there. He said that now he knows that he can file a grievance and leave it in a box.

On 3/19/24 at 1317 Staff C who was present during patients' interviews was asked if she, as patient rights advocate representative, was aware of some patients not being informed about how they can file a grievance. Staff C stated that it was new to her to hear that from the patients. She also shared that she rounds all the units daily and refills grievance forms personally.

Facility's Patient and Family Grievances/Complaints and Role of the Patient Advocate Policy was requested and reviewed. Policy dated 12/2023 indicated:

Grievance Process
2. Patient and their family members shall be informed of the patient's rights and responsibilities upon admission, and the process by which they can voice any concerns related to their rights and/or treatment. This information includes the procedure by which a patient can submit a grievance, (including the name of the patient advocate and the method of access to this individual), the time frame for review of the grievance, and the provision of a written response to the patient within that time frame.