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 policy and procedure review, review of grievance records and interview, it was determined the facility did not adhere to notifying the complainant in writing of the contact person if needed, steps taken on their behalf to investigate the allegations, the results of the grievance process and the date of completion.

A. Review of the policy and procedure "Customer Grievance" revealed:
1) "If a verbal (or telephone) complaint cannot be resolved at the time of the complaint by staff present, or if the complaint is postponed for later resolution or requires investigation, then it is considered a grievance."
2) "A written complaint (including fax or e-mail) is always considered to be a grievance..."
3) "Complaints filed by a friend or family member who is not the patient representative are not considered a grievance..."
4) "Concerns regarding premature discharge are referred to the appropriate utilization review committee..."
5) "The hospital must respond to all grievances within 7 days, including written notification that "the facts have been investigated, applicable persons have been interviewed, the appropriate disciplinary action (if indicated) has been taken and the necessary education (if indicated) has been provided."
B. Review of the grievance records (#15-#18) revealed the following:
1) Grievance Record #15: The patient's mother lodged a grievance on 10/13/11. The grievance was investigated but there was no date to indicate when the investigation was completed. There was no evidence the facility responded back to the complainant in writing.
2) Grievance Record #16: The patient lodged the complaint on 09/29/11. The investigation concluded the physician had documented he repaired two hernias with one piece of mesh and that it was not unheard of for a hernia to reappear if the patient did not restrict activity as instructed. The person taking the grievance added that the patient had expressed to her he was a chronic sneezer. The letter to the Complainant dated 10/03/11 stated the patient would have to take his concerns to the physician as the physician was not employed by the hospital; the letter did not include the contact person, steps taken on their behalf to investigate the allegation, the results of the grievance process and the date completion.
3) Grievance Record #17: The patient lodged the grievance on 08/04/11. The Complainant alleged she had to have a second mammogram done as the breast tissue was not spread out like it should have been and was told she shouldn't have to pay for the second mammogram. The investigation on 08/05/11 revealed the second mammogram was needed in order to get a better diagnostic reading and was not the fault of the technicians; the patient had breast implants and a clearer image was needed for a reading and the doctor explained that to the patient. There was evidence the Complainant was called and the findings reported but there was no evidence the patient received anything in writing.
4) Grievance Record #18. The daughter-in-law lodged a complaint on 07/14/11 and submitted an e-mail with numerous allegations. The investigation included electronic mail (e-mail) from various nursing directors or supervisors. There was a letter dated 07/29/11 addressed to the Complainant and signed by the Vice President of Patient Care. The letter reflected the Complainant's concerns would be investigated and reported back to the Vice President of Patient Care. There was letter to Complainant regarding the contact person at the hospital, steps taken on their behalf to investigate the allegation, the results of the grievance process and the date completion. There was no clear evidence the facility had determined whether the Complainant was considered to be the patient's representative and whether the allegations were considered a grievance and whether or not the complainant was to be notified by letter.
C. Interview on 11/08/11 at 1200, the Vice President of Patient Care Services confirmed the findings for the grievance records.