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 record review and interview, the facility failed to they followed their own policies and procedures regarding providing prompt resolution of 1 out of 4 (#1 ) patients' grievances.


1. Review of the Patient Complaint Resolution/Management/Grievance policy and procedure revealed it became effective September,2003, and last review date of February, 2012. Further review of this policy and procedure revealed the following:

* POLICY: A patient grievance is a formal or written or verbal complaint by a patient, or patient's representative , regarding the patient's care, abuse, or neglect, or Medicare billing complaint related to the rights and limitations provided by 42 CFR 489. A written complaint is always considered a grievance. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with Center for Medicare Services (CMS) requirements are considered a grievance.

* PURPOSE: To Identify trends that impact patient care and customer satisfaction so that processes and outcomes will be improved. To provide a mechanism to resolve patient complaints and grievances that is in compliance with the Center for Medicare and Medicaid Services.

* PROCEDURE: Risk Management will determine type of complaint and refer to appropriate department as necessary and a letter of acknowledgement will be sent to the patient/representative within 7 days, unless issue can be resolved immediately. A grievance log will be maintained to track status of grievances.

Turnaround time for review of complaint and feedback to Risk management by departments is 5 business days.

Risk Management will collaborate with department manager and send letter to author of complaint/grievance within 45 days of original complaint. Resolution will be documented in RiskMaster.

2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was a complaint filed by patient #1's family member on 03/01/2012, regarding patient care.

3. During an interview on 05/01/2012 at 3:30 PM the Risk Manager revealed that they do not have documentation of an investigation and a resolution of a grievance voiced by the family member of Patient #1 .