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Based on policy review, document review, and interview the Hospital failed to ensure the protection and promotion of Patient Rights. The cumulative effects of this deficient practice has the potential to infringe on the rights of all patients or their representatives, to have their grievances investigated and addressed, and hindered the facility's opportunity to discover and address systemic problems that may lead to harm or other adverse outcomes.

Findings Include:

1. The hospital failed to ensure patient rights were provided in accordance with applicable state law (Refer to A0117).

2. The hospital's Governing Body failed to be responsible for and ensuring the implementation of an organized process for the review and resolution of patient grievances (Refer to A0119).

3. The hospital failed to follow facility policy to ensure timely response to patient grievances (Refer to A0122).

4. The hospital failed to ensure grievances were investigated and the results, date of completion, the steps taken on behalf of the patients, and the results of the grievance process were documented and provided to the patient in written form (Refer to A0123).

5. The hospital failed to ensure the consistent implementation of policies to ensure compliance with patient rights for general consent for treatment upon admission (Refer to A0131).

6. The hospital failed to ensure policies and procedures were followed for an alleged abuse investigation (Refer to A0145).

Based on policy review, document review, and interview the Hospital failed to ensure patient rights were provided in accordance with applicable state law affecting eight of ten patients reviewed (Patient 1, 2, 3, 4, 5, 6, 8, and 10). This deficient practice had the potential to affect all patients by not providing patients with all Kansas required patient rights and may lead to harm or other adverse outcomes.


Findings Include:


Review of Kansas Administrative Regulations (KAR) 28-34-3b showed, Patient rights. (a) Policies and procedures. The governing body shall ensure that the facility establishes policies and procedures which support the rights of all inpatients and outpatients. At a minimum, each facility shall ensure that:

(2) each patient has the right, upon request, to be given the name of his attending physician, the names of all other practitioners directly participating in his care and the names and functions of other health care persons having direct contact with the patient...

(3) each patient has the right to make health care decisions. Each patient has the right to the information necessary to make treatment decisions reflecting the patient's wishes and to request a change in his physician or transfer to another health facility due to religious or other reasons...

(6) each patient has the right to assistance in obtaining consultation with another physician or practitioner at the patient's request and own expense...


Review of the Hospital's undated document titled, "Patient Guide," given to all patients upon admission, showed a section titled, "Patient Bill of Rights and Responsibilities" that included 45 different patient rights listed.

The Hospital's "Patient Rights and Responsibilities," failed to include the following:

1. The right to request a change in their physician.

2. The right to request a transfer to another health facility due to religious or other reasons.

3. The right to request assistance in obtaining consultation with another physician or practitioner at the patient's expense.


Review of Patient 1's discharged medical record showed Patient 1's parent signed that they received the Patient Rights that did not include all the state required patient rights.

Review of Patient 2's discharged medical record showed Patient 2's fiancé signed that they received the Patient Rights that did not include all the state required patient rights.

Review of Patient 3's discharged medical record showed Patient 3 was unable to sign the basic consents for treatment and Patient Rights. No medical reason was provided for the unsigned documentation. Further review of the medical record showed no additional attempts by staff.

Review of Patient 4's discharged medical record showed Patient 4 signed that they received the Patient Rights that did not include all the state required patient rights.

Review of Patient 5's discharged medical record showed Patient 5 did not sign the basic consents and receipt of Patient Rights. There was a signature on a witness line, but no medical reason why Patient 5 didn't sign. Further review of the medical record showed that Patient 5 was intoxicated at the time of admission. The medical record showed no evidence Patient 5 was provided with patient rights or consents after she was sober.

Review of Patient 6's discharged medical record showed Patient 6 signed that they received the Patient Rights that did not include all the state required patient rights.

Review of Patient 8's current medical record showed Patient 8 was unable to sign the basic consents and Patient Rights. There was no documentation of a medical reason of why Patient 8 could not sign. The medical record showed that Patient 8's adult son was at bedside and next of kin's consent for treatment and receipt of Patient Rights were not obtained.

Review of Patient 10's current medical record showed Patient 10's parent signed that they received the Patient Rights that did not include all the state required patient rights.


During an interview on 01/13/22 at 9:45 AM, Staff H, Accounts Assistant, stated that when she registers a patient, she provides the patient with the guidebook which contains the patient's rights. If the patient is unable to sign the consent for treatment, the next step is to have family sign. If no family is present, but a next of kin is present in the chart, they call via phone for consent, and a nurse verifies. Staff H stated that employees must make two attempts for consent for treatment to be signed. If a consent is unable to be obtained, staff must document that in the chart, along with a medical reason why the patient cannot sign. Staff H stated that there is a report that can be ran daily and that the financial counselors or the nurses can attempt to obtain the consent for treatment, which also contains the receipt of patient rights.


During an interview on 10/13/22 at 10:51 AM, Staff K, Patient Access Director stated that registration staff attempt to go up the next business day to obtain any signatures missed on admission and that the staff only attempt signatures for consent and patient rights one additional time.


During an interview on 01/13/21 at 10:37 AM, Staff B, Vice Present of Quality and Safety (VPQS), and Staff C, Director of Patient Safety, acknowledged the missing state required Patient Rights.

Based on policy review, document review, and interview the Hospital's Governing Body failed to be responsible for and ensuring the implementation of an organized process for the review and resolution of patient grievances for 16 of 18 patient grievances reviewed (Patients 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, and 26). This deficient practice had the potential to infringe on the rights of all patients or their representatives to have their grievances investigated and addressed and hindered the facility's opportunity to discover and address systemic problems that may lead to harm or other adverse outcomes.


Findings Include:


Review of the Hospital's document titled "Bylaws Governing The Board of Trustees," dated April 2012, showed "The board shall establish and approve a process for prompt resolution of patient grievances that include the provision of information to each patient about whom to contact to file a grievance. The board delegates to the Performance Improvement Steering Committee the responsibility for reviewing and resolving grievances. The Performance Improvement Steering Committee shall periodically submit a report to the Board about the operation of the grievance process, as part of reports about the quality assessment and performance improvement activities of the hospital."

Review of the Hospital's policy titled, "Patient Grievance and Complaint Management Model Policy, dated 08/02/20, showed "Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate, and resolve with the patient and/or patient representative within seven days of receipt of the grievance with the exception of (sic) complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. The risk director will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues . . . documentation will be forwarded to the Director of Risk Management or designated staff member. Data will be aggregated, analyzed and reported by the Director of Risk Management as included in the Quality Assurance Performance Improvement (QAPI) report to the Quality and Patient Safety Committee and the Board of Trustees on a quarterly basis."

Review of the Hospital's document titled "Position Description/Annual Performance Appraisal for Risk Management Coordinator/Patient Advocate," dated 09/17/21, showed that duties include "Ensure that grievances from patients/visitors are submitted to the appropriate areas and grievances are processed according to CMS guidelines, which include follow up correspondence . . . Assists in investigation of serious safety events . . . assists in maintaining the incident reporting system, referring and follow up with managers and directors regarding reports."

Review of the Hospital's documents titled "Board of the Trustees Minutes," dated 01/27/21, 02/24/21, 03/24/21, 04/28/21, 05/26/21, 06/23/21, 07/28/21, 08/25/21, 09/22/21, 10/27/21, and 11/17/21 (December 2021 was not provided to the surveyors) showed that "Quality Updates," did not include reports about the grievance process.

There is no documented evidence to show that the Governing Body was aware of the interruptions in the implementation of the grievance processes. The meeting minutes did not include any information regarding the Performance Improvement Steering Committee or submission of reports to the Board about the operation of the grievance process.

Review of the Grievance log between the dates 07/07/21 through 01/03/22 showed that the Hospital received 64 grievances from patients and/or their representatives. Sixteen of 18 grievances reviewed showed the following:


Patient 10

Review of a grievance dated 11/09/21 showed that the mother of Patient 10 alleged that the hospital had caused broken ribs and a broken wrist while the infant was in the neonatal intensive care unit (NICU) (an intensive care unit specializing in the care of ill or premature newborn infants). Patient 10 was admitted to the NICU on 08/10/21 and discharged home on 10/04/21. Review of the grievance showed "mother presents to hospital and we discuss in person. Sends me pictures of infants (sic) after she got home and points out swelling and bruising of right wrist. Mother states that baby in (sic) [Hospital B] following a fall. Baby was a little fussy and baby's father was holding infant in one of his arms. Mother states that baby has grown, and she told him to use 2 [two] arms. Baby jerked and fell from father's arm in bathroom and hit bathroom sink. Took baby to [Hospital B] to be checked out and is inpatient there now. Found healing rib FX [fractures] and healing wrist FX in xrays (sic)." Further review of the grievance showed Staff P, Physician was asked to re-read the chest X-ray done on 09/20/21, there was no evidence of rib fractures and Staff P brought up the point that a patient with osteopenia will have rib fractures that will show up once they are healed. The grievance document showed Staff Q, Physician was asked to review the record to see if Patient 10 had osteopenia or if there was any other indication of cause for rib/wrist fractures. On 11/18/21 documentation in the grievance showed that Patient 10's mother called for an outcome of the investigation and she was reminded that they were needing the baby's records from Hospital B. The grievance document showed Patient 10's mother had not requested the record from Hospital B and that she would request them.

Further review of the grievance showed that the hospital did not interview staff involved in Patient 10's care. The grievance did not include a notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 10's mother.

During an interview on 01/12/22 at 9:51 AM, Staff B, Vice President of Quality and Safety (VPQS), stated that she did not attempt to contact the hospital that Patient 10 was admitted to. Staff B stated that she did not report the alleged abuse to any state agencies. Staff B stated that she did not conduct any interviews regarding the allegations and had only requested that the neonatologist (a specialist concerned with the care of newborn infants, especially the ill or premature newborn) review Patient 10's medical record. Staff B stated that she was not sure if there were any concerns reported from staff and that she would have to review the social work notes.

During an interview on 01/12/22 at 10:04 AM, Staff C, Director of Patient Safety (DPS), stated that they never got hospital records from Hospital B. Staff C stated that she never attempted to reach out to Hospital B in order to investigate the allegations. Staff C stated that she did not report the alleged abuse to any state agencies and that she only had the information from Patient 10's mother. Staff C could not provide documentation of staff interviews or what the hospital has done to investigate the allegations other than creating a timeline of Patient 10's treatments from a medical chart review.

During an interview on 01/11/22 at 4:15 PM Staff B, Vice President of Quality and Safety (VPQS) stated that there wasn't a letter completed to the patient because they do not have a person in the Patient Advocate/Risk Manager position and that this person would normally complete the resolution letters.


Patient 11

Review of a grievance dated 11/30/21 showed that Patient 11 was deaf, has an intellectual disability and utilizes adapted signs as her primary means of communication. Patient 11's sister notified the hospital that Patient 11 was restrained and could not communicate, staff were wearing masks and the patient could not read lips, and that nobody was communicating with Patient 11 and that Patient 11 required an in-person interpreter.

Further review of the grievance showed the hospital did not investigate the use of the restraint with Patient 11. The grievance showed a note added 12/01/21, "determined that the patient does not use normal sign but a highbred of hand movements that her family understands. Sign interpreter outside of patient room as much as possible in case their services are needed." The hospital identified the signer as a secretary from another floor who used to work at a deaf school.

The grievance documentation failed to include a notification of additional time needed for the investigation and did not include a resolution letter to Patient 11's sister.


Patient 12

Review of a grievance dated 10/27/21 showed that Patient 12 reported that after surgery she was in severe pain, light-headed, and had dry heaves and forced to discharge with the nurses helping her into the vehicle while dry heaving. Patient 12 reported that she felt like an inconvenience to the PACU (post anesthesia care unit) (a specialty unit in a hospital for giving care after sedation and surgery) staff. Further review showed, "Comments/Resolution: Review of PACU care was appropriate for the patient's care." Further review of the grievance documentation showed "Corrective action: pending additional information. The documentation did not include interviews of staff involved with Patient 12's care.

The grievance documentation did not include a notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 12.


Patient 13

Review of a grievance dated 10/07/21 showed that Patient 13's mother called with a complaint of lack of general care, being unable to speak to her son, and that she overheard nurses being rude to her son. The report showed "the caller rambled on with various complaints . . . caller was advised to call ED (Emergency Department) leadership." The various complaints were not documented on the grievance and there is no evidence that those complaints were investigated.

Further review of the grievance documentation showed that the hospital failed to include any interviews, chart review, or documentation showing that the grievance was fully investigated.

The grievance documentation did not include a notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 13's mother.


Patient 14

Review of a grievance dated 11/16/21 showed that Patient 14's mother expressed concern that her son was uncomfortable when a nurse put on a different mask (N95, a mask that is designed to achieve a very close facial fit and very efficient filtration of airborne particles) in order to conduct a COVID-19 test (a nasal swab test used to detect an acute disease caused by coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death). Patient 14's mother was also upset that the doctor would not complete an RSV (Respiratory Syncytial Virus, a virus that causes an infection of the respiratory tract, usually affecting children under the age of 2 years that presents with cold-like symptoms) test at the same time.

Further review of the grievance showed that there was no documentation of an investigation, interviews, or a notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 14's mother.


Patient 15

Review of a grievance dated 11/16/21 showed that Patient 15 had concerns about missing personal affects. The document did not specify what the missing items were.

The grievance did not include documented evidence of an investigation, notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 15.


Patient 16

Review of a grievance dated 12/01/21 showed that Patient 16 had expressed concerns that she was placed in the hallway in a broken recliner in front of the housekeeping closet when there were no other patients in the Emergency Department. Further review showed that Patient 16 was upset that her brace was put on incorrectly and that she was unable to review the x-rays because she was in the hallway.

The grievance did not include documented evidence of an investigation, notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 16.


Patient 17

Review of a grievance dated 12/03/21 showed that Patient 17's mother called to report concerns that the hospital had spelled her son's name incorrect on his medical records, Protected Health Information (PHI) (protected health information under the law is any information about health status, provision of health care, or payment for health care that is created or collected by a covered entity and can be linked to a specific individual) and HIPAA (The Health Insurance Portability and Accountability Act of 1996, a law that prohibits healthcare providers and healthcare businesses from disclosing protected information to anyone other than a patient and the patient's representatives without their consent).

The grievance did not include documented evidence of an investigation, notification that the hospital would require additional time in order to investigate and did not include a resolution letter to Patient 17's mother.

During an interview on 01/13/22 at 10:37 AM Staff C, Director of Patient Safety (DPS), stated that she did not investigate the concerns and did not know the outcomes or resolutions that were made. Staff C stated that the grievance was given to Staff D, PHI and HIPAA Officer. Staff C stated that she did not complete a letter to the complainant.

During an interview on 01/13/22 at 11:48 AM, Staff D, PHI and HIPAA Officer, stated that Patient 17's name was corrected and that it was not addressed with the triage nurse who entered it incorrectly. Staff D stated that it was addressed with registration who should be double checking against the insurance cards. Staff D stated that there were no PHI or HIPAA concerns and that she sends the results of her investigations back to the Director of Patient Safety. Staff D stated that she does not keep track of patient complaints unless they are a violation of PHI or HIPAA. Staff D stated that she did not complete a letter to the complainant.


Patient 18

Review of a grievance dated 12/08/21 showed Patient 18 reported that the Emergency Department Physician told her that she was ER (emergency room) hopping, that the reasons she was there was a waste of time, that her primary care physician cannot track trends, that they will not send the lab work to her primary care physician and being dismissive. Patient 18 reported that there was no reason to stay since the doctor felt that way and when she got the discharge paperwork that it showed pancreatitis (inflammation of the pancreas, a long, flat gland that sits behind the stomach in the upper abdomen, that produces enzymes that help digestion and hormones that help regulate the way your body processes sugar) was a possibility and that she could die. Patient 18 reported that nobody verbally told her this information. Patient 18 also claimed that the doctor was talking badly about her in the hallway and that the nurse apologized for the doctor's behavior. Further review of the grievance showed a comment, "Patient [Patient 18] was receiving treatment and decided to leave AMA (against medical advice)."

The grievance documentation did not include notification to Patient 18 that the hospital would require additional time in order to investigate and did not include a resolution letter to the complainant.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that she did not interview the physician or nurse. Staff C stated that the patient was at the ED to receive treatment but left against medical advice. Staff C stated that Staff E, Director of Emergency Department (DED), was assigned to investigate the complaint. Staff C does not know the outcome of the grievance.

During an interview on 01/13/22 at 11:00 AM, Staff E, DED, stated that she spoke with the nurse but did not interview the doctor, that the Medical Director would interview him. Staff E stated that she did not document the conversation with the nurse.


Patient 19

Review of a grievance dated 12/08/21 showed that Patient 19 was sent to the ED by his primary care physician who arranged an admittance to the hospital through the ED. The grievance included that Patient 19 got lab work and a CT scan (computerized tomography, a scan that combines a series of x-ray images taken from different angles around the body and uses computer processing to create cross-sectional images) but did not get a physical exam. The grievance also included concerns that the ED physician did not admit Patient 19 to the hospital and that the ED physician refused to contact the patient's primary care physician or the physician in which the admittance was arranged.

The grievance documentation did not include notification to Patient 19 that the hospital would require additional time in order to investigate and did not include a resolution letter to the complainant.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that she did not interview the physicians regarding the incidents. She stated that it would have been escalated to the Staff F, Chief Medical Officer (CMO). Staff C stated that she does not know the outcome of the grievance and that she did not complete a letter to the complainant.

During an interview on 01/13/22 at 10:51 AM Staff F, CMO, stated that he delegated the investigation to Staff G, Medical Director of the Emergency Department (MDED). Staff F stated that he does not know the outcome of the investigation.


Patient 20

Review of a grievance dated 12/10/21 showed that Patient 20 had numerous complaints through the labor and delivery of her child that included the quick inflation of a cervix catheter (a tube with a balloon on the end of it that is inserted through the opening of the cervix (cylinder-shaped neck of tissue that connects the vagina and uterus) and filled with sterile water to assist with the progression of dilation, the opening of the cervix), numerous dilation checks using the butterfly position (mother on back, knees bent and spread apart) that caused a lot of pain due to hip issues, lack of repositioning, lack of lactation (breastfeeding) support, and pressure from the financial office to pay her bill prior to leaving the hospital. Patient 20 also stated that the hospital was not able to provide mesh underwear (disposable underwear made of lightweight mesh used after birth) or an abdominal binder (a wide compression belt that encircles your abdomen to provide support to the surgical site) that would fit her. The grievance had a note that the team would discuss the concerns on 12/15/21.

The grievance documentation did not include notification to Patient 20 that the hospital would require additional time in order to investigate and did not include a resolution letter to the complainant.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that the team did meet to discuss the concerns. Staff C stated that Patient 20 was heavy set and they put two abdominal binders together to accommodate her size and that she refused assistance with turning. Staff C stated that Patient 20 was provided Acetaminophen (a medication used to treat pain) and Flexeril (a medication to treat muscle spasms or pain) when the cervix catheter was inserted and filled. Staff C stated that mothers are encouraged to take lactation classes ahead of time and that the lactation consultant had met with her during her stay. Staff C stated that she had not completed a notification to extend the investigation to Patient 20. Staff C stated that she did not send a letter to Patient 20 outlining the findings of the investigation.


Patient 22

Review of a grievance dated 12/20/21 showed Patient 22's mother had concern with how the ED physician treated her 20-month-old son and herself. Patient 22's mother stated that the ED physician told her and her son that there was no need to be so dramatic, that he despises this age group because they can be so difficult, and asked Patient 22 if he wanted a snack, he had to stop crying. When the nurse on duty brought Patient 22 a snack, the physician had stated that the nurse was much nicer than he would be.

The grievance documentation did not include notification to Patient 22's mother that the hospital would require additional time in order to investigate.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that the grievance came in before Christmas and she is unsure if it has been looked at by the Staff G, Medical Director of the ED (MDED). Staff C stated that she has not provided a notification extending the time needed in order to investigate the grievance.


Patient 23

Review of a grievance dated 12/20/21 showed Patient 23 expressed concerns that a physical exam was documented in her patient portal when the physician did not complete a physical exam. Patient 23 expressed that the CT and EKG (a test that measures the electrical activity of the heart to detect cardiac problems) had been read but that nobody has called her with the results Patient 23 also reported that the nurse had taken her vital signs prior to leaving the ED but that they were not documented in the patient portal.

The grievance documentation did not include notification to Patient 23 that the hospital would require additional time in order to investigate.


Patient 24

Review of a grievance dated 12/21/21 showed Patient 24's wife expressed concerns that Patient 24 needed to be discharged to rehab, that occupational therapy (OT) (a profession that helps people across the lifespan do things that they want and need to do through the therapeutic use of daily activities) was not available until 01/05/22 and the social worker was not aware of that, concerns with pain management, discharge planning with home health, staff were rude, no baths were given during his stay, delayed responses to the call light, and that four sores were found on the Patient 24's back.

The grievance documentation did not include notification to Patient 24's wife that the hospital would require additional time in order to investigate.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that a nurse had spoken with Patient 24's wife and that she was upset because OT was not available until 01/05/22 and that the Medical Director had followed up with the nurse. Staff C did not provide any further information regarding the concerns. Staff C stated that a notification extending the time needed for an investigation was not completed and that a resolution letter to the complainant was not completed.


Patient 25

Review of a grievance dated 12/30/21 showed that Patient 25's son had concerns about Patient 25's missing personal property.

The grievance documentation did not include notification to Patient 25's son that the hospital would require additional time in order to investigate and did not complete a letter to the complainant outlining the findings of the investigation.


Patient 26

Review of a grievance dated 12/30/21 showed that Patient 26's daughter had concerns about Patient 26's missing personal property.

The grievance documentation did not include notification to Patient 26's daughter that the hospital would require additional time in order to investigate and did not complete a letter to the complainant outlining the findings of the investigation.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that a notification extending the time needed to complete the investigation was not completed. Staff C stated that the property could not be located. The hospital did not complete a letter to the complainant outlining the findings of the investigation.

During an interview on 01/11/22 at 4:15 PM Staff B, VPQS stated that no grievance resolution letters were sent to patients because the Patient Advocate/Risk Manager position is vacant. During an interview on 01/12/22 at 4:00 PM Staff B, VPQS, stated that they have not had a Patient Advocate/Risk Manager in place since February 2021.

Based on policy review, document review, and interview, the Hospital failed to follow policy to ensure a timely response to grievances for 16 of 18 patient grievances reviewed (Patients 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, and 26). This deficient practice had the potential to delay timely response to grievances that infringed on the rights of all patients or their representatives to have their grievances investigated and addressed and hindered the facility's opportunity to discover and address systemic problems that may lead to harm or other adverse outcomes.


Findings Include:


Review of the Hospital's policy titled, "Patient Grievance and Complaint Management Model Policy," dated 08/02/20, showed "Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate, and resolve with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. The risk director will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues . . . occasionally, a grievance is complicate and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days."

Review of the Hospital's document titled "Position Description/Annual Performance Appraisal for Risk Management Coordinator/Patient Advocate," dated 09/17/21, showed that duties include "Ensure that grievances from patients/visitors are submitted to the appropriate areas and grievances are processed according to CMS (Center for Medicare & Medicaid Services) guidelines, which include follow up correspondence . . . Assists in investigation of serious safety events . . . assists in maintaining the incident reporting system, referring and follow up with managers and directors regarding reports."

Review of the Grievance log between the dates 07/07/21 through 01/03/22 showed that the Hospital received 64 grievances from patients and/or their representatives. Sixteen of 18 grievances reviewed showed:


Patient 10

Review of a grievance dated 11/09/21 showed that the mother of Patient 10 alleged that the hospital had caused broken ribs and a broken wrist while the infant was in the neonatal intensive care unit (NICU) (an intensive care unit specializing in the care of ill or premature newborn infants). Patient 10 was admitted to the NICU on 08/10/21 and discharged home on 10/04/21. Review of the grievance showed "mother presents to hospital and we discuss in person. Sends me pictures of infants (sic) after she got home and points out swelling and bruising of right wrist. Mother states that baby in (sic) [Hospital B] following a fall. Baby was a little fussy and baby's father was holding infant in one of his arms. Mother states that baby has grown, and she told him to use 2 [two] arms. Baby jerked and fell from father's arm in bathroom and hit bathroom sink. Took baby to [Hospital B] to be checked out and is inpatient there now. Found healing rib FX [fractures] and healing wrist FX in xrays (sic)." The hospital documented that Patient 10's mother called for an outcome of the investigation on 11/18/21. The hospital informed Patient 10's mother that they had not received the records from Hospital B showing the alleged fractures.

Further review of the grievance showed that the hospital did not interview staff involved in Patient 10's care. The grievance did not include a notification that the hospital would require additional time in order to investigate and the grievance did not include a resolution letter to the complainant.

During an interview on 01/12/22 at 9:51 AM, Staff B, Vice President of Quality and Safety (VPQS), stated that she did not attempt to contact the hospital that Patient 10 was admitted to. Staff B stated that she did not report the alleged abuse to any state agencies. Staff B stated that she did not conduct any interviews regarding the allegations and had only requested that the neonatologist (a specialist concerned with the care of newborn infants, especially the ill or premature newborn) review Patient 10's medical record. Staff B stated that she was not sure if there were any concerns reported from staff and that she would have to review the social work notes.

During an interview on 01/12/22 at 10:04 AM, Staff C, Director of Patient Safety (DPS), stated that they never got hospital records from Hospital B. Staff C stated that she never attempted to reach out to Hospital B in order to investigate the allegations. Staff C stated that she did not report the alleged abuse to any state agencies and that she only had the information from Patient 10's mother. Staff C could not provide documentation of staff interviews or what the hospital has done to investigate the allegations other than creating a timeline of Patient 10's treatments from a medical chart review.


Patient 11

Review of a grievance dated 11/30/21 showed that Patient 11 was deaf, has an intellectual disability and utilizes adapted signs as her primary means of communication. Patient 11's sister notified the hospital that Patient 11 was restrained and could not communicate, staff were wearing masks and the patient could not read lips, and that nobody was communicating with Patient 11 and that Patient 11 required an in-person interpreter.

Further review of the grievance documentation showed the hospital did not investigate the use of the restraint with Patient 11. The grievance showed a note added 12/01/21, "determined that the patient does not use normal sign but a highbred of hand movements that her family understands. Sign interpreter outside of patient room as much as possible in case their services are needed." The hospital identified the signer as a secretary from another floor who used to work at a deaf school. The hospital failed to ensure a mechanism of communication for Patient 11 by utilizing a family member who can understand Patient 11's adapted signs.

There was no documented evidence to show the hospital provided notification to Patient 11's sister that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 12

Review of a grievance dated 10/27/21 showed that Patient 12 reported that after surgery she was in severe pain, light-headed, and had dry heaves and forced to discharge with the nurses helping her into the vehicle while dry heaving. Patient 12 reported that she felt like an inconvenience to the PACU (post anesthesia care unit) (a specialty unit in a hospital for giving care after sedation and surgery) staff. Further review showed, "Comments/Resolution: Review of PACU care was appropriate for the patient's care." Further review of the grievance documentation showed "Corrective action: pending additional information. The documentation did not include interviews of staff involved with Patient 12's care.

There was no documented evidence to show the hospital provided notification to Patient 12 that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 13

Review of a grievance dated 10/07/21 showed that Patient 13's mother called with a complaint of lack of general care, being unable to speak to her son, and that she overheard nurses being rude to her son. The report showed "the caller rambled on with various complaints . . . caller was advised to call ED (Emergency Department) leadership." The various complaints were not documented on the grievance and there is no evidence that those complaints were investigated.

Further review of the grievance showed no documented evidence of any interviews, record review, or documentation showing that the grievance was fully investigated. There was no documented evidence to show the hospital provided notification to Patient 13's mother that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 14

Review of a grievance dated 11/16/21 showed that Patient 14's mother expressed concern that her son was uncomfortable when a nurse put on a different mask (N95, a mask that is designed to achieve a very close facial fit and very efficient filtration of airborne particles) in order to conduct a COVID-19 test (a nasal swab test used to detect an acute disease caused by coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death). Patient 14's mother was also upset that the doctor would not complete an RSV (Respiratory Syncytial Virus, a virus that causes an infection of the respiratory tract, usually affecting children under the age of 2 years that presents with cold-like symptoms) test at the same time.

There was no documented evidence to show the hospital provided notification to Patient 14's mother that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 15

Review of a grievance dated 11/16/21 showed that Patient 15 had concerns about missing personal affects. The document did not specify what the missing items were.

There was no documented evidence of an investigation concerning Patient 15's missing personal affects. There was no documented evidence to show the hospital provided notification to Patient 15 that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.



Patient 16

Review of a grievance dated 12/01/21 showed that Patient 16 had expressed concerns that she was placed in the hallway in a broken recliner in front of the housekeeping closet when there were no other patients in the Emergency Department. Further review showed that Patient 16 was upset that her brace was put on incorrectly and that she was unable to review the x-rays because she was in the hallway.

There was no documented evidence to show an investigation of Patient 16's concerns. There was no documented evidence to show the hospital provided notification to Patient 16 that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 17

Review of a grievance dated 12/03/21 showed that Patient 17's mother called to report concerns that the hospital had spelled her son's name incorrect on his medical records, Protected Health Information (PHI) (protected health information under the law is any information about health status, provision of health care, or payment for health care that is created or collected by a covered entity and can be linked to a specific individual) and HIPAA (The Health Insurance Portability and Accountability Act of 1996, a law that prohibits healthcare providers and healthcare businesses from disclosing protected information to anyone other than a patient and the patient's representatives without their consent).

During an interview on 01/13/22 at 10:37 AM Staff C, Director of Patient Safety (DPS), stated that she did not investigate the concerns and did not know the outcomes or resolutions that were made. Staff C stated that the grievance was given to Staff D, PHI and HIPAA Officer. Staff C stated that she did not complete a letter to the complainant.

During an interview on 01/13/22 at 11:48 AM, Staff D, PHI and HIPAA Officer, stated that Patient 17's name was corrected and that it was not addressed with the triage nurse who entered it incorrectly. Staff D stated that it was addressed with registration who should be double checking against the insurance cards. Staff D stated that there were no PHI or HIPAA concerns and that she sends the results of her investigations back to the Director of Patient Safety. Staff D stated that she does not keep track of patient complaints unless they are a violation of PHI or HIPAA. Staff D stated that she did not complete a letter to the complainant.

There was no documented evidence to show the hospital provided notification to Patient 17' mother that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 18

Review of a grievance dated 12/08/21 showed Patient 18 reported that the Emergency Department Physician told her that she was ER (emergency room) hopping, that the reasons she was there was a waste of time, that her primary care physician cannot track trends, that they will not send the lab work to her primary care physician and being dismissive. Patient 18 reported that there was no reason to stay since the doctor felt that way and when she got the discharge paperwork that it showed pancreatitis (inflammation of the pancreas, a long, flat gland that sits behind the stomach in the upper abdomen, that produces enzymes that help digestion and hormones that help regulate the way your body processes sugar) was a possibility and that she could die. Patient 18 reported that nobody verbally told her this information. Patient 18 also claimed that the doctor was talking badly about her in the hallway and that the nurse apologized for the doctor's behavior. Further review of the grievance showed a comment, "Patient [Patient 18] was receiving treatment and decided to leave AMA (against medical advice)."

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that she did not interview the physician or nurse. Staff C stated that the patient was at the ED to receive treatment but left against medical advice. Staff C stated that Staff E, Director of Emergency Department (DED), was assigned to investigate the complaint. Staff C does not know the outcome of the grievance.

During an interview on 01/13/22 at 11:00 AM, Staff E, DED, stated that she spoke with the nurse but did not interview the doctor, that the Medical Director would interview him. Staff E stated that she did not document the conversation with the nurse.

There was no documented evidence to show the hospital provided notification to Patient 18 that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 19

Review of a grievance dated 12/08/21 showed that Patient 19 was sent to the ED by his primary care physician who arranged an admittance to the hospital through the ED. The grievance included that Patient 19 got lab work and a CT scan (computerized tomography, a scan that combines a series of x-ray images taken from different angles around the body and uses computer processing to create cross-sectional images) but did not get a physical exam. The grievance also included concerns that the ED physician did not admit Patient 19 to the hospital and that the ED physician refused to contact the patient's primary care physician or the physician in which the admittance was arranged.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that she did not interview the physicians regarding the incidents. She stated that it would have been escalated to the Staff F, Chief Medical Officer (CMO). Staff C stated that she does not know the outcome of the grievance and that she did not complete a letter to the complainant.

During an interview on 01/13/22 at 10:51 AM Staff F, CMO, stated that he delegated the investigation to Staff G, Medical Director of the Emergency Department (MDED). Staff F stated that he does not know the outcome of the investigation.

There was no documented evidence to show the hospital provided notification to Patient 19 that the hospital would require additional time in order to investigate and there was no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 20

Review of a grievance dated 12/10/21 showed that Patient 20 had numerous complaints through the labor and delivery of her child that included the quick inflation of a cervix catheter (a tube with a balloon on the end of it that is inserted through the opening of the cervix (cylinder-shaped neck of tissue that connects the vagina and uterus) and filled with sterile water to assist with the progression of dilation, the opening of the cervix), numerous dilation checks using the butterfly position (mother on back, knees bent and spread apart) that caused a lot of pain due to hip issues, lack of repositioning, lack of lactation (breastfeeding) support, and pressure from the financial office to pay her bill prior to leaving the hospital. Patient 20 also stated that the hospital was not able to provide mesh underwear (disposable underwear made of lightweight mesh used after birth) or an abdominal binder (a wide compression belt that encircles your abdomen to provide support to the surgical site) that would fit her. The grievance had a note that the team would discuss the concerns on 12/15/21.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that the team did meet to discuss the concerns. Staff C stated that Patient 20 was heavy set and they put two abdominal binders together to accommodate her size and that she refused assistance with turning. Staff C stated that Patient 20 was provided Acetaminophen (a medication used to treat pain) and Flexeril (a medication to treat muscle spasms or pain) when the cervix catheter was inserted and filled. Staff C stated that mothers are encouraged to take lactation classes ahead of time and that the lactation consultant had met with her during her stay. Staff C stated that she had not completed a notification to extend the investigation to Patient 20. Staff C stated that she did not send a letter to Patient 20 outlining the findings of the investigation.

There was no documented evidence to show the hospital provided notification to Patient 20 that the hospital would require additional time in order to investigate and no documented evidence to show the hospital provided a resolution letter of the grievance to the patient.


Patient 22

Review of a grievance dated 12/20/21 showed Patient 22's mother had concern how the ED physician treated her 20-month-old son and herself. Patient 22's mother stated that the ED physician told her and her son that there was no need to be so dramatic, that he despises this age group because they can be so difficult, and asked Patient 22 if he wanted a snack, he had to stop crying. When the nurse on duty brought Patient 22 a snack, the physician had stated that the nurse was much nicer than he would be.

There was no documented evidence to show the hospital provided notification to Patient 22's mother that the hospital would require additional time in order to investigate.

During an interview on 01/13/22 at 10:37 AM, Staff C, Director of Patient Safety (DPS), stated that the grievance came in before Christmas and she is unsure if it has been looked at by the Staff G, Medical Director of the ED (MDED). Staff C stated that she has not provided a notification extending the time needed in order to investigate the grievance.


Patient 23

Review of a grievance dated 12/20/21 showed Patient 23 expressed concerns that a physical exam was documented in her patient portal when the physician did not complete a physical exam. Patient 23 expressed that the CT and EKG (a test that measures the electrical activity of the heart to detect cardiac problems) had been read but that nobody has called her with the results Patient 23 also reported that the nurse had taken her vital signs prior to leaving the ED but that they were not documented in the patient portal.

There was no documented evidence to show the hospital provided notification to Patient 23 that the hospital would require additional time in order to investigate.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that the grievance has not gotten to Staff G, MDED, yet, but that it will be. Staff C stated that a notification extending the time needed for the investigation was not completed.


Patient 24

Review of a grievance dated 12/21/21 showed Patient 24's wife expressed concerns that Patient 24 needed to be discharged to rehab, that occupational therapy (OT) (a profession that helps people across the lifespan do things that they want and need to do through the therapeutic use of daily activities) was not available until 01/05/22 and the social worker was not aware of that, concerns with pain management, discharge planning with home health, staff were rude, no baths were given during his stay, delayed responses to the call light, and that four sores were found on the Patient 24's back.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that a nurse had spoken with Patient 24's wife and that she was upset because OT was not available until 01/05/22 and that the Medical Director had followed up with the nurse. Staff C did not provide any further information regarding the concerns. Staff C stated that a notification extending the time needed for an investigation was not completed and that a resolution letter to the complainant was not completed.


Patient 25

Review of a grievance dated 12/30/21 showed that Patient 25's son had concerns about Patient 25's missing personal property.


Patient 26

Review of a grievance dated 12/30/21 showed that Patient 26's daughter had concerns about Patient 26's missing personal property.

During an interview on 01/13/22 at 10:37 AM, Staff C, DPS stated that a notification extending the time needed to complete the investigation was not completed. Staff C stated that Patient 25 and Patient 26's property could not be located. The hospital did not complete a letter to the complainant outlining the findings of the investigation.


During an interview on 01/11/22 at 4:15 PM Staff B, Vice President of Quality and Safety (VPQS) stated that there wasn't a resolution letter completed to provide the patients because they do not have a person in the Patient Advocate/Risk Manager position and that this person would normally complete the resolution letters.

Based on policy review, document review, and interview the Hospital failed to ensure patient grievances were investigated and the results, date of completion, the steps taken on behalf of the patients, and the results of the grievance process were documented and provided to the patient in written form for 11 of 18 grievances reviewed (Patients 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20). This deficient practice had the potential to cause harm and other adverse outcomes for all patients.


Findings Include:


Review of the Hospital's policy titled, "Patient Grievance and Complaint Management Model Policy," dated 08/02/20, showed, "In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

Review of the Hospital's document titled "Position Description/Annual Performance Appraisal for Risk Management Coordinator/Patient Advocate," dated 09/17/21, showed that duties include "Ensure that grievances from patients/visitors are submitted to the appropriate areas and grievances are processed according to CMS guidelines, which include follow up correspondence . . . Assists in investigation of serious safety events . . . assists in maintaining the incident reporting system, referring and follow up with managers and directors regarding reports."

Review of the Grievance log between the dates 07/07/21 through 01/03/22 showed that the Hospital received 64 grievances from patients and/or their representatives. 11 of 18 grievances reviewed showed:


Patient 10

Review of a grievance dated 11/09/21 showed that the mother of Patient 10 alleged that the hospital had caused broken ribs and a broken wrist while the infant was in the neonatal intensive care unit (NICU) (an intensive care unit specializing in the care of ill or premature newborn infants). Patient 10 was admitted to the NICU on 08/10/21 and discharged home on 10/04/21. Review of the grievance showed "mother presents to hospital and we discuss in person. Sends me pictures of infants (sic) after she got home and points out swelling and bruising of right wrist. Mother states that baby in (sic) [Hospital B] following a fall. Baby was a little fussy and baby's father was holding infant in one of his arms. Mother states that baby has grown, and she told him to use 2 [two] arms. Baby jerked and fell from father's arm in bathroom and hit bathroom sink. Took baby to [Hospital B] to be checked out and is inpatient there now. Found healing rib FX [fractures] and healing wrist FX in xrays (sic)." Further review of the grievance showed Staff P, Physician was asked to re-read the chest X-ray done on 09/20/21, there was no evidence of rib fractures and Staff P brought up the point that a patient with osteopenia will have rib fractures that will show up once they are healed. The grievance document showed Staff Q, Physician was asked to review the record to see if Patient 10 had osteopenia or if there was any other indication of cause for rib/wrist fractures. On 11/18/21 documentation in the grievance showed that Patient 10's mother called for an outcome of the investigation and she was reminded that they were needing the baby's records from Hospital B. The grievance document showed Patient 10's mother had not requested the record from Hospital B and that she will request them.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.


Patient 11

Review of a grievance dated 11/30/21 showed that Patient 11 was deaf, has an intellectual disability and utilizes adapted signs as her primary means of communication. Patient 11's sister notified the hospital that Patient 11 was restrained and could not communicate, staff were wearing masks and the patient could not read lips, and that nobody was communicating with Patient 11 and that Patient 11 required an in-person interpreter.

Further review of the grievance showed the hospital did not investigate the use of the restraint with Patient 11. The grievance showed a note added 12/01/21, "determined that the patient does not use normal sign but a highbred of hand movements that her family understands. Sign interpreter outside of patient room as much as possible in case their services are needed." The hospital identified the signer as a secretary from another floor who used to work at a deaf school. The hospital failed to ensure a mechanism of communication for Patient 11 by utilizing a family member who can understand Patient 11's adapted signs.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.



Patient 12

Review of a grievance dated 10/27/21 showed that Patient 12 reported that after surgery she was in severe pain, light-headed, and had dry heaves and forced to discharge with the nurses helping her into the vehicle while dry heaving. Patient 12 reported that she felt like an inconvenience to the PACU (post anesthesia care unit) (a specialty unit in a hospital for giving care after sedation and surgery) staff. Further review showed, "Comments/Resolution: Review of PACU care was appropriate for the patient's care." Further review of the grievance showed "Corrective action: pending additional information. The documentation did not include interviews of staff involved with Patient 12's care.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.


Patient 13

Review of a grievance dated 10/07/21 showed that Patient 13's mother called with a complaint of lack of general care, being unable to speak to her son, and that she overheard nurses being rude to her son. The report showed "the caller rambled on with various complaints . . . caller was advised to call ED (Emergency Department) leadership." The various complaints were not documented.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.



Patient 14

Review of a grievance dated 11/16/21 showed that Patient 14's mother expressed concern that her son was uncomfortable when a nurse put on a different mask (N95, a mask that is designed to achieve a very close facial fit and very efficient filtration of airborne particles) in order to conduct a COVID-19 test (a nasal swab test used to detect an acute disease caused by coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death). Patient 14's mother was also upset that the doctor would not complete an RSV (Respiratory Syncytial Virus, a virus that causes an infection of the respiratory tract, usually affecting children under the age of 2 years that presents with cold-like symptoms) test at the same time.

There was no documented evidence to show the hospital investigated the concerns or provided a resolution letter within 28 days of receipt of the complaint.


Patient 15

Review of a grievance dated 11/16/21 showed that Patient 15 had concerns about missing personal affects. The document did not specify what the missing items were.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.


Patient 16

Review of a grievance dated 12/01/21 showed that Patient 16 had expressed concerns that she was placed in the hallway in a broken recliner in front of the housekeeping closet when there were no other patients in the Emergency Department. Further review showed that Patient 16 was upset that her brace was put on incorrectly and that she was unable to review the x-rays because she was in the hallway.

There was no documented evidence to show the hospital investigated the concerns or provided a resolution letter within 28 days of receipt of the complaint.


Patient 17

Review of a grievance dated 12/03/21 showed that Patient 17's mother called to report concerns that the hospital had spelled her son's name incorrect on his medical records, Protected Health Information (PHI) (protected health information under the law is any information about health status, provision of health care, or payment for health care that is created or collected by a covered entity and can be linked to a specific individual) and HIPAA (The Health Insurance Portability and Accountability Act of 1996, a law that prohibits healthcare providers and healthcare businesses from disclosing protected information to anyone other than a patient and the patient's representatives without their consent).

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.

During an interview on 01/13/22 at 10:37 AM Staff C, Director of Patient Safety (DPS), stated that she did not investigate the concerns and did not know the outcomes or resolutions that were made. Staff C stated that the grievance was given to Staff D, PHI and HIPAA Officer. Staff C stated that she did not complete a letter to the complainant.

During an interview on 01/13/22 at 11:48 AM, Staff D, PHI and HIPAA Officer, stated that Patient 17's name was corrected and that it was not addressed with the triage nurse who entered it incorrectly. Staff D stated that it was addressed with registration who should be double checking against the insurance cards. Staff D stated that there were no PHI or HIPAA concerns and that she sends the results of her investigations back to the Director of Patient Safety. Staff D stated that she does not keep track of patient complaints unless they are a violation of PHI or HIPAA. Staff D stated that she did not complete a letter to the complainant.



Patient 18

Review of a grievance dated 12/08/21 showed Patient 18 reported that the Emergency Department Physician told her that she was ER (emergency room) hopping, that the reasons she was there was a waste of time, that her primary care physician cannot track trends, that they will not send the lab work to her primary care physician and being dismissive. Patient 18 reported that there was no reason to stay since the doctor felt that way and when she got the discharge paperwork that it showed pancreatitis (inflammation of the pancreas, a long, flat gland that sits behind the stomach in the upper abdomen, that produces enzymes that help digestion and hormones that help regulate the way your body processes sugar) was a possibility and that she could die. Patient 18 reported that nobody verbally told her this information. Patient 18 also claimed that the doctor was talking badly about her in the hallway and that the nurse apologized for the doctor's behavior. Further review of the grievance showed a comment, "Patient [Patient 18] was receiving treatment and decided to leave AMA (against medical advice)."

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.

During an interview on 01/13/22 at 11:00 AM, Staff E, DED, stated that she spoke with the nurse but did not interview the doctor, that the Medical Director would interview him. Staff E stated that she did not document the conversation with the nurse.


Patient 19

Review of a grievance dated 12/08/21 showed that Patient 19 was sent to the ED by his primary care physician who arranged an admittance to the hospital through the ED. The grievance included that Patient 19 got lab work and a CT scan (computerized tomography, a scan that combines a series of x-ray images taken from different angles around the body and uses computer processing to create cross-sectional images) but did not get a physical exam. The grievance also included concerns that the ED physician did not admit Patient 19 to the hospital and that the ED physician refused to contact the patient's primary care physician or the physician in which the admittance was arranged.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.

During an interview on 01/13/22 at 10:51 AM Staff F, CMO, stated that he delegated the investigation to Staff G, Medical Director of the Emergency Department (MDED). Staff F stated that he does not know the outcome of the investigation.


Patient 20

Review of a grievance dated 12/10/21 showed that Patient 20 had numerous complaints through the labor and delivery of her child that included the quick inflation of a cervix catheter (a tube with a balloon on the end of it that is inserted through the opening of the cervix (cylinder-shaped neck of tissue that connects the vagina and uterus) and filled with sterile water to assist with the progression of dilation, the opening of the cervix), numerous dilation checks using the butterfly position (mother on back, knees bent and spread apart) that caused a lot of pain due to hip issues, lack of repositioning, lack of lactation (breastfeeding) support, and pressure from the financial office to pay her bill prior to leaving the hospital. Patient 20 also stated that the hospital was not able to provide mesh underwear (disposable underwear made of lightweight mesh used after birth) or an abdominal binder (a wide compression belt that encircles your abdomen to provide support to the surgical site) that would fit her. The grievance had a note that the team would discuss the concerns on 12/15/21.

During an interview on 01/13/22 at 10:37 AM Staff C, DPS stated that the team did meet to discuss the concerns. Staff C stated that Patient 20 was heavy set and they put two abdominal binders together to accommodate her size and that she refused assistance with turning. Staff C stated that Patient 20 was provided Acetaminophen (a medication used to treat pain) and Flexeril (a medication to treat muscle spasms or pain) when the cervix catheter was inserted and filled. Staff C stated that mothers are encouraged to take lactation classes ahead of time and that the lactation consultant had met with her during her stay. Staff C stated that she had not completed a notification to extend the investigation to Patient 20. Staff C stated that she did not send a letter to Patient 20 outlining the findings of the investigation.

There was no documented evidence to show the hospital provided a resolution letter within 28 days of receipt of the complaint.


During an interview 01/11/22 at 4:15 PM Staff B, Vice President of Quality and Safety (VPQS), stated that the grievances did not have final letters written to patients because the Risk Management/Patient Advocate position was vacant.

During an interview on 01/12/22 at 4:00 PM Staff B, VPQS, stated that they have not had a Patient Advocate/Risk Manager in place since February 2021.

Based on policy review, medical record review, and interview the Hospital failed to ensure the consistent implementation of policies to ensure compliance with patient rights for general consent for treatment upon admission to the facility for three of eight patients (Patients 3, 5, and 8) reviewed. This deficient practice had the potential to affect all patients and may lead to an infringement on patient rights that may lead to harm or other adverse outcomes.

Findings Include:

Review of the hospitals document titled, "Conditions of Admission and Consent for Outpatient Care," dated 12/01/20, showed "Consent to Treatment. I consent to the procedures that may be performed during this hospitalization or during an outpatient episode of care, including, but not limited to, emergency treatment or services, and which may include laboratory procedures, x-ray examination, diagnostic procedures, medical, nursing, or surgical treatment or procedures, anesthesia, or hospital services rendered as ordered by the Provider."

Further review of the document showed an area for the patient or the patient representative to sign, a witness to sign, and an additional witness if the patient is unable to sign without a representative or patients that refuse to sign.

Review of the Hospital's document titled "Registrar Job Summary," undated, showed job duties included "Ensure that all necessary signatures are obtained for treatments; Answers any questions and explains policies clearly."


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was unable to sign the basic consents for treatment and Patient Rights. No medical reason was provided for the unsigned documentation. Further review of the medical record showed no additional attempts to obtain were made by staff.


Patient 5

Review of Patient 5's discharged medical record showed Patient 5 did not sign the basic consents and receipt of Patient Rights. There was a signature on a witness line, but not on the second line, and no medical reason why Patient 5 didn't sign. Further review of the medical record showed that Patient 5 was intoxicated at the time of admission. The medical record showed no evidence Patient 5 was provided with patient rights or consents after she was sober.


Patient 8

Review of Patient 8's current medical record showed Patient 8 was unable to sign the basic consents and Patient Rights. There was no documentation of a medical reason of why Patient 8 could not sign. The medical record showed that Patient 8's adult son was at bedside and consent for treatment and receipt of Patient Rights were not obtained.


During an interview on 01/13/22 at 9:45 AM, Staff H, Accounts Assistant, stated that when she registers a patient, she provides the patient with the guidebook which contains the patient's rights. If the patient is unable to sign the consent for treatment, the next step is to have family sign. If no family is present, but a next of kin is present in the chart, they call via phone for consent, and a nurse verifies. Staff H stated that employees must make two attempts for consent for treatment to be signed. If a consent is unable to be obtained, staff must document that in the chart, along with a medical reason why the patient cannot sign. Staff H stated that there is a report that can be ran daily and that the financial counselors or the nurses can attempt to obtain the consent for treatment, which also contains the receipt of patient rights.

During an interview on 10/13/22 at 10:51 AM, Staff K, Patient Access Director stated that registration staff attempt to go up the next business day to obtain any signatures missed on admission and that the staff only attempt signatures for consent and patient rights one additional time.

Based on policy review, document review, and interview the Hospital failed to implement policies and procedures that direct a full investigation of an allegations of abuse, failed to protect other patients from potential abuse, and failed to report the alleged abuse to child protective services and the State Agency for one patient (Patient 10) of one alleged abuse grievance reviewed. This deficient practice had the potential to infringe on the rights of all patients to be free from all forms of abuse or harassment and may lead to harm or other adverse outcomes.


Findings Include:


Review of the Hospital's policy tiled, "Abuse, Neglect, Exploitation of a Child," dated 12/30/21, showed, "It is the responsibility of each health care provider, who has reasonable cause to believe that a child (age less than 18 years) treated at or admitted to [Hospital] has been or is being abused, neglected, or sexually exploited to report the suspicion to the appropriate authorities after conferring with his/her director, manger, house supervisor, or Director of Risk Management . . . If the suspected abuse, neglect, or exploitation is substantiated (confirmed) the Director Patient Safety/Risk notifies [State Agency] and [local police department]."


Review of the Hospital's undated document titled, "Patient guide," given to all patients upon admission, showed a section titled, "Patient Bill of Rights and Responsibilities." Further review showed all patients had the right "to be free from all forms of abuse and punishment."

Patient 10

Review of a grievance dated 11/09/21 showed that the mother of Patient 10 alleged that the hospital had caused broken ribs and a broken wrist while the infant was in the neonatal intensive care unit (NICU) (an intensive care unit specializing in the care of ill or premature newborn infants). Patient 10 was admitted to the NICU on 08/10/21 and discharged home on 10/04/21. Review of the grievance showed "mother presents to hospital and we discuss in person. Sends me pictures of infants (sic) after she got home and points out swelling and bruising of right wrist. Mother states that baby in (sic) [Hospital B] following a fall. Baby was a little fussy and baby's father was holding infant in one of his arms. Mother states that baby has grown, and she told him to use 2 [two] arms. Baby jerked and fell from father's arm in bathroom and hit bathroom sink. Took baby to [Hospital B] to be checked out and is inpatient there now. Found healing rib FX [fractures] and healing wrist FX in xrays (sic)." Further review of the grievance showed Staff P, Physician was asked to re-read the chest X-ray done on 09/20/21, there was no evidence of rib fractures and Staff P brought up the point that a patient with osteopenia will have rib fractures that will show up once they are healed. The grievance document showed Staff Q, Physician was asked to review the record to see if Patient 10 had osteopenia or if there was any other indication of cause for rib/wrist fractures. On 11/18/21 documentation in the grievance showed that Patient 10's mother called for an outcome of the investigation and she was reminded that they were needing the baby's records from Hospital B. The grievance document showed Patient 10's mother had not requested the record from Hospital B and that she would request them.

Further review of the grievance showed that the hospital did not interview staff involved in Patient 10's care. The grievance did not include a notification that the hospital would require additional time in order to investigate. The grievance did not include a resolution letter to the complainant.

During an interview on 01/12/22 at 9:51 AM, Staff B, Vice President of Quality and Safety (VPQS), stated that she did not attempt to contact the Hospital B. Staff B stated that she did not report the alleged abuse to any state agencies. Staff B stated that she did not conduct any interviews regarding the allegations and had only requested that the neonatologist (a specialist concerned with the care of newborn infants, especially the ill or premature newborn) review Patient 10's medical record.

During an interview on 01/12/22 at 10:04 AM Staff C, Director of Patient Safety (DPS), stated that she had spoken with Patient 10's mother and that she had reported that Patient 10 has healing rib fractures and a wrist fracture and was at the time, currently admitted at another local hospital. Staff C stated that the mother alleged the injuries happened while the patient was admitted here because the injuries were old. Staff C stated that she had a physician re-read the last x-rays that were completed at their hospital dated 09/20/21 and that no fractures were evident. Staff C stated that she did not call child protective services or report the allegations to the State Agency. Staff C stated that she only had the information that Patient 10's mother provided her. Staff C stated that a timeline of Patient 10's treatments while at the hospital was completed. Staff C stated that she did not interview all the staff involved in Patient 10's care. When Staff C was asked if she had investigated whether staff missed any concerns or suspicion of parental behavior, Staff C did not answer. Staff B, VPQS, who was present during the interview, stated that she would have to look at the social worker's notes.