Mon Health Medical Center

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 40269 Based on document reviews, and staff interviews, it was determined the facility failed to follow the complaint and grievance policy in one (1) complaint filed on behalf of patient #1. This failure has the potential to negatively impact all patients at the facility. Findings include: A policy was reviewed titled “Patient & Family Complaints and Grievances”, publication date 03/2022. The policy states in part, “Policy: A complaint is an oral or written expression of displeasure or dissatisfaction with service which can be resolved immediately by staff present or can be forwarded to the appropriate department for resolution. A complaint escalates to grievance status when not immediately resolved to the patient ’ s/family ’ s satisfaction by the involved staff member or department, therefore requiring further intervention by another organizational representative. Complaints from patients/families who call or write to the hospital after being discharged, and are not immediately resolved as defined above, are considered grievances. The hospital must provide a written (response) to each grievance. Written responses may also be sent if the patient/family requests a letter in response to a complaint or if the complaint is difficult to communicate with verbally. As needed the patient/family may be asked to submit their complaint/ grievance in writing ... Procedure: 1. Patient/Family Complaints/Grievance Received in Person, In Writing, or Telephonically: The staff member who first receives or has knowledge of a patient/family complaint is responsible for initiating service recovery and the complaint resolution process ... b. The Department/Unit Director, House Supervisor, designated representative, or Executive Staff member will review the complaint report, investigation findings, document any additional information in the “follow up” section of the occurrence reporting system and determine the appropriate follow up actions. Letters of resolution should be sent in response to grievances within 7 days and must contain the following elements: - Name of the hospital contact person, - Steps taken to investigate the grievance, - Results of the grievance process, - Date of completion ... If the grievance will not be resolved, or if the investigation will not be completed within 7 days, the Patient Advocate or the Department Director shall inform the patient or the patient’s representative that they are still working to resolve the grievance and will follow up with a written response within 21 days. c. The patient Advocate or the Director of Quality and/or Risk Management should be notified immediately and be involved at any time deemed appropriate. d. If a meeting is requested by the person making the complaint, the Director of Quality and/or Risk Management should be included as it is appropriate and possible ... 4. Notification of Results: a. When it is determined that written notification shall be provided to a complainant, such notification shall occur within seven (7) days and will contain the name of the hospital contact person, the steps taken to investigate the complaint, the results of the complaint process, and the date on which the complaint was resolved/addressed. b. If the grievance is complex and requires extensive investigation for resolution greater than seven (7) days, the Patient Advocate or designee must inform the patient or representative that the hospital is still working to resolve the grievance and will follow up with a written response and provide expected date of response ...” The complaint/grievance log was reviewed for the past six (6) months. The complaint filed on behalf of the patient was listed on the log on 04/24/24 with a description summary of the complainant’s concerns. An initial letter was sent to the complainant on 04/30/24. No final letter or conclusion had been sent. The facility did not have any documentation an investigation was conducted into the complainant’s concerns. The Unit Director, Emp #15, responsible for the nursing investigation no longer worked at the facility and did not respond to requests for an interview. The Patient Advocates investigation states, “Spoke with staff who share that the patient requested [Patient #1’s HCS] to not be notified of [Patient #1’s] stay inpatient.” No further documentation was provided. An interview was conducted with Emp #4 on 08/12/24 at 1:15 p.m. Regarding Patient #1, Emp #4 states in part, “I did not know the patient before 4/24. When we went into the room the patient wasn’t responding just the [Patient #1’s HCS] was talking. There was a concern why no one informed the [Patient #1’s HCS] that the [Patient #1] was there. I asked the staff, and my understanding was that when [Patient #1] was still conversing with staff [Patient #1] said [Patient #1] didn’t want [Patient #1’s HCS] to know [Patient #1] was there. When [Patient #1] was deemed to lack capacity, they reached out to the [Patient #1’s HCS] for healthcare surrogate to consent to surgery. As the state police told [Patient #1’s HCS] the patient was not at the hospital anymore. I was not aware that the psychiatrist asked for numbers for the patient to notify [Patient #1’s] family. I wasn’t aware that the patient requested to contact [Patient #1’s] family. I was told that the patient did not want [Patient #1’s HCS] to know [Patient #1] was there. It was the patient’s wishes to not have [Patient #1’s HCS] informed. The patient did not tell me this, this came from nursing staff. The patient did not talk to me. There was another issue asking about medical records and I walked the [Patient #1’s HCS] through the process to obtain the medical records. There was an issue about staff caring for the patient’s hygiene needs and it was addressed right there. The [Patient #1’s HCS] became combative and verbally aggressive with staff.” Regarding the complaint, Emp #4 states, “An interim letter was sent. Those were the only complaints of the time; the patient never filed a formal grievance. I stopped in to check on the patient and patient’s [HCS] a few other times. [Patient #1’s HCS] was constantly angered with staff. I did not know about the issue with visitor restriction. I did not do any further investigation as I thought that the problem was settled at the time.” An interview with Emp #3 on 08/14/24 at 10:30 a.m. confirmed there was no other information related to this complaint and the final letter had not been sent due to it “Falling off [Emp #4] task list.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 40269 Based on document reviews, medical record reviews, and staff interviews, it was determined the facility failed to follow nursing documentation procedures by not documenting the events leading to visitation restrictions in one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients at the facility. Findings include: A policy was reviewed titled “Patient’s Rights and Responsibilities”, last reviewed 09/2022. The policy states in part, “... Patient’s Rights: ... B. Each patient has the right to consent to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member or a friend . The patient also has the right to withdraw ordering such consent at any time. The HOSPITALS will not restrict, limit or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. All visitors will enjoy full and equal visitation privileges consistent with patient preferences. The HOSPITALS allow a family member, friend or another individual to be present for emotional support during the course of the stay. Each patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission, and to involve them in decisions about care, treatment or services ...” A policy was reviewed titled “Patient Visitation Guidelines”, last reviewed 08/2022. The policy states in part, “... Definitions: Justify Clinical Restrictions-means any clinically necessary or reasonable restriction or limitation imposed on a patient ’ s visitation rights which restriction or limitation is necessary to provide safe care to patient or any other patient. A justified Clinical Restriction may include, but need not be limited to, one or more of the following: ... - Behavior presenting a direct risk or threat to the patient, hospital staff, or others in the immediate environment ... C. General Guidelines - 1. Visitors are welcome at any time 24/7 in non-restricted areas, providing that their conduct does not jeopardize patient safety or impact patient care by disruptive behavior ... 6. Visitation may be restricted by court order, provider’s order, supervisor, or patient’s request ...” A medical record review was conducted for Patient #1. The patient presented to the facility’s Emergency Department (ED) on 04/09/24 with a chief complaint of pain and infection. The patient had been treated at another facility for a retroperitoneal abscess and signed out against medical advice (AMA). The patient was admitted to the facility with diagnosis of retroperitoneal abscess, perinephric abscess, pleural effusion, and acute metabolic encephalopathy. On 04/12/24 at 12:40 p.m. a “Nursing Note” by Emp #16 states, “Contacted house supervisor regarding incident that occurred on prior floor. No documentation found in chart.” On 04/15/24 at 12:23 p.m. a “Progress Note” by Emp #7 states in part, “...Patient concerned with inability to see family.” On 04/16/24 a “Progress Notes” by Emp # 14 states in part, “... [Patient #1] is upset because [Patient #1] is not allowed to have visitors and is worried because [Patient #1] has not been able to call and talk to [Patient #1’s family]. States that [Patient #1] is missing [Patient #1’s] family. Does not have any phone numbers for [Patient #1’s] family members as they are in [Patient #1’s] cell phone and [Patient #1] does not have [Patient #1’s] phone at this time. Security reported to nursing that the phone had been confiscated and is in police possession. [Patient #1] is also concerned that [Patient #1’s] family has not been able to call and check on [Patient #1’s] as they do not have the code. Patient states [Patient #1] does not know what the code is to give them even if [Patient #1] had a phone number and was able to call them from [Patient #1’s] phone in [Patient #1’s] Hospital room ... Continue to restrict visitors ...” May it be noted, no documentation was found in Patient #1’s medical record that the patient was placed on visitor restrictions, the events leading up to this restriction at the time, or the notification and understanding of this restriction to the patient. An interview was conducted with Emp #3 on 08/12/24 at 1:15 p.m. Emp #3 explains A visit restriction would be a joint effort between security, nursing, nursing leadership, risk, and provider. Visitor restrictions should be documented. An interview was conducted with Emp #7 on 08/12/24 at 2:33 p.m. Regarding Patient #1, Emp #7 states in part, “... I was aware that the patient was on visitor restrictions however I was not involved in the visitor restriction. This was passed on by nursing staff ...” An interview was conducted with Emp #14 on 08/14/24 at 9:35 a.m. Regarding Patient #1, Emp #14 states in part, “... For the previous visitor restrictions, I wasn’t aware because nothing was documented. I would expect that something would have been documented in the medical record so I would know the extent of what happened ... I did express my concern over the lack of documentation about the visitor restrictions and had a meeting afterwards to discuss it. I suggested that the nurses should document everything that is true so that all the providers are aware ...” An additional interview was conducted with Emp #9 on 08/14/24 at 10:55 a.m. Regarding Patient #1, Emp #9 states, “I do remember having a conversation with the psychiatric provider about documentation. When an incident happens, nursing usually calls for advice about what to document. In this case it was determined the documentation in the incident report would be enough. I made it aware to the nursing supervision to have nursing document factual relevant information in the patient’s medical record in the event of an incident happening. I don’t remember why they didn’t go back and document the incident in this case. The reason the patient is on visitor restriction and that that restriction was provided to the patient should be documented in the medical record.””