HospitalInspections.org

Based on review of the hospital's policy and procedure for the "Important Message from Medicare" (IM), titled "Utilization Review Plan," Section H, and interviews with hospital staff (floor, leadership, and administrative), it was determined that the policy and procedure failed to include the following key points as required in the regulation:
1) The time frame by which the IM must be provided to the patient or responsible party at admission and discharge.
2) Who is responsible for the providing patients with the IM.
3) Where the IM is maintained on the patient record.

Based on a review of the hospital Patient Handbooks and Complaint policies, it was determined that 1) the hospital policy does not currently distinguish between complaints and grievances, and therefore, complaints which qualify as grievances may not be handled per grievance regulatory directives, and 2) the hospital handbook and policies fails to describe the complaint/grievance process. In addition, since the brain injury unit is CARF accredited, the complaint policies and patient handbooks for the two units have conflicting information regarding filing complaints with outside agencies or advocacy groups and lacks contact information for hospital staff identified in handbooks as those responsible for complaints and grievances. It should be noted that the two specialty units have received only one complaint in the past 18 months that could not be resolved immediately.

Based on review of Complaint Policy, it was determined that the governing body has not delegated in writing the responsibility to review and resolve grievances to a grievance committee or other body charged with investigating complaints and grievances. The hospital refers all complaints and grievances to each unit's Clinical Manager and Program Director for investigation, who then report up through the quality oversight process, but the policy fails to include a specific statement from the governing body delegating this pathway. It should be noted that the hospital has received no grievances in the past 18 months, and only one complaint that could not be resolved immediately.

Based on review of the hospital patient complaint procedure, it was determined that the hospital policy does not specify that the average length of time for resolution of grievances is expected to be seven days or less. The hospital has received only one complaint in the past 18 months that could not be resolved immediately, and it was resolved in three days. The hospital does provide complainants with a report that includes the summary of the complaint, actions taken to resolve the complaint, and the outcome along with the name of the hospital contact person who investigated and resolved the complaint.

Based on review of the hospital's Restraint Policy and Procedure, it was determined that the policy fails to specify that the order for restraints must be received immediately. The policy calls for a physician's order within one hour of the application of restraints. It should be noted that the hospital has not had any restraint episodes for at least four years.

Based on review of the patient handbook and the hospital visiting policy, the hospital's policy does not specify that a patient may name a support person and have that person make decisions regarding visitation if the patient is not capable. In addition, the patient handbook does not notify the patient and/or the support person of his or her right to receive or restrict visitors including but not limited to spouse, domestic partner (including a same-sex domestic partner), another family member, or friend.