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 clinical record review, review of Facility policies and procedures, and staff interview, it was determined the Facility failed to have a process in place to communicate patient concerns after they had been voiced, in 1 (#5) of 20 (#1-#20) clinical records reviewed. This failed process prevented the Facility from acting in a prompt manner, for complaint resolution after a complaint had been voiced. Findings follow

1. Review of clinical record #5 , revealed a Patient with an admitting date of 09/25/15 at 2134, to Labor and Delivery Triage.
A. The Patient was seen by the [Named] Resident Physician on 09/26/15 at 12:11 am who documented the following:
1) ..."She was diagnosed with IUFD [Intrauterine Fetal Demise] in Clinic Wednesday 09/16/15...".
2) ..."She expressed desire to induce labor at this time."
3) ..."Due to lack of beds available on Labor and Delivery, and shortage of housekeeping staff to clean rooms at this time, it was explained to patient that induction could not start right now."
4) ..."It was explained to the patient that even though some rooms were empty, they have not been cleaned yet. There is currently a shortage of housekeeping staff in the hospital tonight...".
B. The Attending Physician documented on 09/26/15 ..."I agree with the residents note and plan of care. Due to lack of beds we asked the pt [Patient] to return tomorrow for induction of labor...".
C. On 09/26/15 at 12:11 am, the Resident Physician documented
..."The patient voiced displeasure with the current situation...".
D. There was no evidence to indicate Facility Administrators were made aware of the concern the patient verbalized.

2. Review of the Agency Policy titled, "Patient Complaints and Grievances" (PS.2.03) revealed a policy that stated the following:
A. ..."All complaints and grievances shall be addressed and notice of the Hospital's determination provided to the patient or representative in a timely manner...".
B. ..."Staff Present- Includes any hospital staff present at the time the complaint is communicated or who can quickly be at patient's location (i.e. Unit Supervisors, Unit Directors, Hospital Administration, Patient Advocates, etc.) to resolve the patient's complaint."
C. Verbal complaints received at the time of service should be addressed as soon as possible by the employee to whom the complaint is directed, the Unit Supervisor, Unit Ddirector or Administrator on Call. If attempts to resolve the complaint are unsuccessful, the Patient Advocate and/or Ethics Team, as appropriate, should be contacted. If the issue remains unresolved, it will be handled as a grievance.

3. An interview was conducted on 01/27/16, with the Director of Labor and Delivery who verbalized ..."We were not aware of the situation. We did not even know this had happened...".