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.

ELKHART GENERAL HOSPITAL 600 E BLVD ELKHART, IN 46514 Oct. 21, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, the facility failed to follow its grievance policy for 1 of 4 (patient 27) grievances reviewed.

Findings:

1. The policy/procedure Patient Grievance Process (approved 2-13) indicated the following: "The manager and/or director review the medical record (MR), conduct a formal investigation and query other members of the healthcare team that have been involved in the care of the patient. "

2. On 10-21-14 at 0915 hours, the risk manager A2 and the director of performance improvement A3 were requested to provide all documentation related to a grievance initially received by the facility on 8-12-14 from patient 27.

3. The 8-12-14 grievance documentation provided for review lacked evidence of a formal investigative process including documentation of interviews with staff identified in the MR or related to a resolution of the issues.

4. On 10-21-14 at 1325 hours, nursing director A7 and the director of performance improvement A3 were requested to provide additional documentation to validate the investigation process including any findings from interviews conducted with staff identified in the MR or associated with the facility response for resolving the issue(s) or concern(s) and none was provided prior to exit.

5. During an interview on 10-21-14 at 1325 hours, nursing director A7 confirmed that they (A7) conducted a brief interview with a nurse associated with the issue(s) or concern(s) and confirmed that no documentation of the interview was available.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review and interview, the facility failed to develop a procedure for investigating allegations of patient abuse or mistreatment by a staff member in accordance with the patient right to be free from all forms of abuse.

Findings:

1. The policy/procedures titled Victims of Abuse Plan (approved 11-13), Progressive Disciplinary Program (approved 6-11), Nursing Chain of Command (approved 11-13) and Patient Grievance Process (approved 2-13) failed to indicate a procedure for responding to allegations involving patient abuse or mistreatment by a staff member including a process for objectively investigating the allegations and for protecting patients at risk for abuse until an investigation is completed.

2. During an interview on 10-21-14 at 1700 hours, the vice president of nursing A1 confirmed that the facility lacked a written procedure for investigating allegations of patient abuse by a staff member.