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Based on policy review, document review, and interview the Critical Access Hospital failed to identify, acknowledge, and respond to a grievance for 1 (Patient 1) of 4 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes.

Findings Include:


Review of the Hospital's policy titled, "Customer Grievance/Concern Resolution (Complaints), GA-182," revised 02/25/22, showed, that the purpose of the policy was " ...Provide a collaborative process for the acknowledgment, evaluation and expedient resolution of all grievances and concerns (complaints) of patients." ..."A patient grievance is a written (an Email or fax is considered "written") or verbal complaint (when the verbal complaint about patient/resident care is not resolved at the time of the complaint, by staff present) by patient regarding the patient's care, abuse or neglect, issues related to the hospital's compliance ... " ...All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance for the purposes of these requirements.". . . "B. Unresolved complaints will be considered a grievance and entered into CS Stars (Hospital Grievance System). Grievances will be handled as follows:

1. Within seven days the customer will receive a telephone call or a written response acknowledging receipt or resolution of the complaint.

2. An investigation of the complaint will be initiated, and the appropriate staff contacted.

3. Within 30 days the customer will be provided written notice of action taken regarding the grievance. Should the investigation take longer than 30 days, the customer or their representative/guardian will be notified in writing. The final notice will contain the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process and the date of completion."

Patient 1

Review of Patient 1's medical record showed she was admitted on 12/23/22 at 4:57 PM with a diagnosis of Acute exacerbation of chronic obstructive airway disease (acute worsening of respiratory symptoms with increased inflammation in airways with mucus) and elevated troponin (diagnostic marker of damage to the heart).

Review of Patient 1's medical record "sexual assault note" dated 12/27/23, by Staff U, Registered Nurse (RN) SANE SART (Sexual Assault Nurse Examiner and Sexual Assault Response Team), showed "I (Patient 1) told the nurse I needed the Purewick (external catheter for female urinary incontinence) checked. She didn't check but went and got the CNA (Certified Nurse Aide). The RN got mouthy with me and I told her I wanted to file a sexual assault ...That woman just jammed her fingers in me without gloves."

Review of the CAH's document titled, "Incident Log," for the dates of 08/01/22 to 04/03/23, showed an incident involving Patient 1 alleging Abuse/Neglect/Exploitation that occurred on 12/26/22.

Review of the "Event Report, Initial Event Description", "Statement from the House Supervisor" Staff N, RN entered on 12/28/22 at 10:47 AM, showed, "at approximately 8:15 PM on 12/26/22, Staff P RN, approached me in the ED and informed me that while Staff L, CNA and Staff M, CNA were in room to obtain vital signs the patient had made a statement that she had been sexually assaulted by day shift."

The Event Report failed to show acknowledgment, evaluation, expedient resolution, and lacked a response to Patient 1's complaint regarding abuse.

Review of the Hospital document titled, "Patient Complaints/Grievances" dated 08/01/22 to 04/03/23 failed to show Patient 1's complaint of abuse that allegedly occurred on 12/26/22.

During interview on 04/03/23 at 7:57 PM, Patient 1 stated that she didn't remember the CNA's name and didn't care. She stated that the CNA walked over to her bed and said, "are you going to be a bitch all day." Patient 1 stated that this was the 3rd time that the incontinence Purewick was used on her in a hospital. She stated that it was making a puttering noise like passing gas didn't know if that was normal. She stated that the RN (Registered Nurse) told her she would fix it in a second. Then she sent in a CNA that had been going off on her earlier in the hallway and been very nasty with her. She stated that they didn't change the Purewick and that she put her two fingers into vagina without gloves then jammed it into her. Patient 1 stated that she tried to talk to the RN. Patient 1 stated that the RN said, "No you been talking bad about my staff." Patient 1 stated, "So I called 911." Patient 1 stated that a male and female officer showed up and would be not press charges. She stated that they said it was an error in training and the prosecutor agreed and they left at 3:00 AM. Patient 1 stated that the forensic nurses from Hospital B were all nice, they did a pelvic, including a rape kit with swabs. She stated that when Hospital B was called to find out about rape kit, Hospital B's lawyer sent a letter saying Patient 1 was not allowed to contact Hospital B. Patient 1 stated that the forensic nurse was made aware the CNA was still at nurses' station. Patient 1 stated that she wanted to go to another hospital since didn't feel safe after the sexual assault.

During interview on 04/05/23 at 9:03 AM Staff A, RN DON (Director of Nursing), stated that she was made aware of allegation on 12/26/22. She stated that she received a called from Staff O, Human Resources Director who was the night shift AOC (administrator on call). The event happened on day shift, so I told them to call SANE SART and risk. She stated that the patient didn't identify the staff by name. The investigation started immediately after the allegation was made. Staff A stated that she did not personally speak to patient because it was a risk and SANE SART case.

During interview on 04/05/23 at 9:57 AM Staff R, RN Risk Manager, stated that she was made aware of allegation on 12/26/22 between 7:30-8:30 PM and an investigation was started immediately. She stated that she did not speak to Patient 1. Staff R stated that the complaint was kept as an incident report because of the continued criminal investigation. No letter was sent since the patient advocate would only send a letter if it was a grievance.