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 document review and interview, it was determined for 1 of 4 (Pt #1) patient, the Hospital failed to ensure complaints/grievances were identified, logged, and followed up on in accordance with Hospital policy.

Findings include:

1. The policy titled "Allegations of Patient Abuse or Neglect While Receiving Care" was reviewed on 2/23/16 at approximately 3:00 PM. The policy addressed allegations of abuse related to employees and stated under "Definitions" that it "does not include any hospital, medical, healthcare, or other personal care services done in good faith in the interest of the patient." Under "Policy", it stated patients have the right to be free from the "fear of being abused or neglected" and employees are to report "any and all
information concerning occurrences where abuse or neglect may have occurred. This obligation may include protection from visitors..." The policy further stated "a disagreement... is not grounds for conducting an investigation of abuse or neglect. b. These issues are more appropriately addressed through other processes such as discussion with the patient's treatment team, the grievance process, or review by clinical supervisors or administrative personnel."

2. The policy titled "Patient Complaints and Grievances" was reviewed on 2/23/16 at approximately 11:25 AM. The policy stated "Definitions: Patient grievance: Written or verbal complaint (when verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or a patient's representative, regarding patient's care, abuse or neglect, issues related to the hospital's compliance with Centers for Medicare/Medicaid Services (CMS) Hospital Conditions of Participation ... Process: Addressing/Documenting Complaint/Grievance... 2. Any complaint or allegation of abuse, neglect, or discrimination is directed to department manager, supervisor, or nursing supervisor. 3. a. Any complaint of abuse, neglect, or discrimination is to be reported to and investigated by patient relations and is classified as a grievance ... c. Patient relations staff maintains communication with patient/family unless otherwise noted ... 5. All Grievances needing further clinical staff evaluation or risk notification will follow those predetermined processes..."

3. Pt #1 ' s record was reviewed on 2/23/16 thru 2/24/16. Pt #1 was admitted on [DATE] with the diagnosis [DIAGNOSES REDACTED] for scheduled inpatient chemotherapy treatment with discharge when the Methotrexate level was less than 0.05. On 9/4/15 at 2:16 AM, the Interdisciplinary (IDT) note stated " Patient became very upset and tearful this evening around 1:15 am. Patient was crying uncontrollably about a social situation from the nursing home, related to insurance and information being disclosed to " ... (Ins Rep #1) " . The charge RN (Registered Nurse) ... (E#11) spent 15-20 minutes talking with the patient trying to calm... (Pt #1) down. The patient finally settled and went to sleep

4. A phone interview was conducted with the Charge Nurse (E#11) on 2/24/16 at approximately 10:20 AM. When asked if any recollection of Pt #1 on 9/3/15 to 9/4/15, E#11 stated " heard sounds from... (Pt#1)'s room and... (Pt#1) was sitting in the window, crying uncontrollably and saying ' ... (Ins Rep #1 ' s first name) wasn ' t suppose to tell them that. I thought maybe... (Pt#1) was on the phone, but... (Pt#1) said something like... (Pt#1) didn ' t want to see... (Ins Rep#1) anymore. I didn ' t know who ... (Ins Rep #1 ' s first name) was. I was probably in... (Pt#1)'s room for an hour or more afterwards trying to calm... (Pt#1) down. I reported it in report to the next shift. When a patient has a request for no visitors, I talk to the Case Manager, but I wasn ' t really sure who this was or what was going on so I reported it in the shift report. "

5. An interview was conducted with the Registered Nurse (E#10) who cared for Pt #1 9/3/15 thru 9/4/15 night shift, on 2/24/16 at approximately 10:25 AM. E#10 concurred with E#11 ' s interview contents. E#10 stated Pt #1 "was talking about someone named ... (Ins Rep #1 ' s first name) and complaining about insurance and disclosing information to them and the nursing home that... (Pt#1) didn ' t think they (the Hospital) should be doing that... (Pt#1) is usually very talkative and chatty but... Pt#1) seemed pretty angry and withdrawn which is totally out of character for... (Pt#1). " When asked what the process is if a patient requests for a person not to be allowed to visit, E#10 stated " We can put a sign on their door that says to check with the nurse ' s station before visiting or we can do a ' Do not publish ' which we ' d report to the Charge Nurse. "

6. An interview was conducted with Patient Relations (E#20) on 2/23/16 at approximately 3:50 PM with the Accreditation Coordinator (E#1) and the Manager Patient Relations (E#5) present. E#20 stated Pt #1 called me to ask how to get this lady (Ins Rep #1) to stop visiting because... (Ins Rep #1) was driving... (Pt #1) crazy. I called the floor (where the patient was located) and the Charge Nurse said they were aware. I tried to call and see who to call about this. I then called ... (E#21) at Corporate. Corporate then contacted the insurance company and asked that ... (Ins Rep #1) no longer visit... (Pt #1)... I remember a comment that this happened before and I don't want it to happen this time" When asked what further action was taken, E#20 stated "When it happens as an inpatient, it doesn't get documented because it is dealt with in real-time in accord with the complaint/grievance process." When asked why this would not have been considered a Patient Rights concern due to Pt #1 feelings related to Ins Rep #1, and therefore follow the grievance process, E#20 stated Ins Rep #1 "was an insurance representative and when the patient signs their consent for treatment, they agree for them to have access to their records. They (some insurance companies) have been doing this (sending insurance representatives) to the Hospital to see patients during their stay more over the last couple of years. Most of them (patients) seem to like it. This was the first time with a complaint. We didn't think of it as a Patient Rights issue or as a grievance, but now that we're talking it through, I can see how it could be seen in both ways and is an opportunity for improvement." Both E#1 and E#5 verbally agreed with the statements of E#20.

7. The Complaint/Grievance log for September 2015 thru February 2016 of complaints related to Patient Rights was reviewed on 2/23/16. The log lacked documentation of Pt #1's complaint/grievance as stated during the interview with E #20 above.