The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interview and record review the hospital failed to ensure each patient was provided with information on how to file a grievance (complaint) and whom to contact to file a grievance. Specifically, the hospital failed to explain that grievances could be filed with the facility, the State Agency, or Joint Commission. In addition, the facility failed to provide contact information in order to file a grievance with the facility, the State Agency, and Joint Commission. Findings:

Review of the "patient rights & responsibilities" pamphlet, provided to patients on admission, revealed rights of patients at ANMC (Alaska Native Medical Center) included the right to "Voice complaints regarding your care and have them addressed without fear of it affecting your care." Further review revealed no documentation on how to voice complaints or whom to contact to file a complaint.

During an interview on 8/18/11 at 8:10 am, Customer Service Staff #1 was asked how patients could file complaints. She replied that patients could call the customer service phone or could fill out a comment card, which are located at 16 boxes throughout the hospital.

Review of the "Inpatient Room Guide", given to patients on admission, revealed the following reference related to the comment cards: "We encourage you to write questions and concerns down so that you may communicate this to your health care team immediately. Comments cards are available throughout the hospital. All comments can be submitted anonymously." Further review revealed no documentation informing patients that comment cards could be used to file complaints.

During interviews on 8/18/11 from 2:45 - 3:15 pm, patients were asked how they would file a complaint. Patient #11 stated she did not know how to file a complaint and added "They didn't give me anything." Patient #12 stated he guessed he would call the number posted on the wall a "Couple of days ago".

Review of the posted information on the wall revealed contact information for, and directions to, the Customer Service Department. The posted information also referenced the comment cards: "You can fill out a comment form and place it in the comment drop box located in each unit. Boxes are located outside each elevator on each floor. These boxes are checked daily." Further review revealed no specific documentation informing patients that in addition to positive comments, the comment cards could also be used to file complaints.

Review of the hospital policy "Patient Grievance Policy #110" revealed that ANMC would provide written notice to all patients regarding their right to make a complaint or grievance and that such notice informs patients about:

whom to contact at ANMC to file a grievance or complaint;

what procedure to use to make complaints and grievances;

the patient's right to lodge a grievance with the State of Alaska Department of Health and Social Services, regardless of whether the patient has first used ANMC's grievance process.

the telephone number and address of the State representative; and

the right to voice concerns about quality of care to The Joint Commission.