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 hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by the hospital staff's failure to correctly identify and investigate/respond to patient grievances for 2 (#1, #2) of 2 patients reviewed for complaints/grievances.


Review of the hospital policy titled, Patient Grievance Management, Policy number: OHS.QUAL.008, Date of Issue: December 2013, revealed in part:

I. Purpose: The purpose of this policy is to establish a mechanism for the reporting, prompt management and resolution of patient grievances when the patient's expectation of care and services are not met.

II. Definitions: Patient complaint- verbal communication to the hospital by a patient, or the patient's representative, regarding the patient's care or non-care issue that can be resolved immediately by staff present.

Patient grievance- is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP).

Staff present: includes any staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, patient advocates, etcetera) to resolve the patient's complaint.

Patient Grievance Management:
A. When a patient or family member expresses a concern or issue to a staff member (complaint): 1. The staff member will attempt to promptly resolve the issue as soon as possible. (Examples of issues that routinely result in prompt resolution by staff members include, but are not limited to, a change in bedding, housekeeping of a room, serving of preferred food and beverages, etcetera). If the issue can be promptly resolved, formal documentation of the concern is not required.
B. When an issue cannot be promptly resolved (grievance):
1. The patient relations representative will initiate the grievance process by entering data into the electronic tracking system.
2. The patient relations representative will immediately forward a copy of the grievance to the appropriate investigators (Hospital Manager/Director or physician) by electronic email.

Patient #1
Review of the Hospital's complaints/grievances revealed the following complaint made by Patient #1 to a hospital Patient Relations Representative, dated 5/30/16 at 10:15 a.m., Classification: Complaint; Incident date: 5/29/16; Department: Dietary; Feedback Categories: Appropriateness of diet and selection of food items.

Description/Comments: Patient #1 stated he had ordered a salad over the weekend and got the end pieces of a tomato and very little iceberg lettuce. He also stated he had to call Food and Nutrition Services 3 times yesterday because his food had salt in it. Patient #1 stated he spoke to the Food and Nutrition Supervisor yesterday but hasn't gotten a response yet.

Further review of the complaint intake documentation, presented by S1AsstVPPI (Assistant Vice President of Performance Improvement), revealed no documented evidence that the complaint had been passed on to the appropriate department representative nor was there any documentation of investigation and/or follow up on Patient #1's expressed food quality/dietary concerns referenced in the intake.

In an interview on 9/08/16 at 11:05 a.m. with S3PtExpMgr (Patient Experience Manager-Food and Nutrition Services), he indicated he had not been notified of Patient #1's food service related complaint taken by the Patient Relations Representative on 5/30/16. S3PtExpMgr further indicated he was not sure which Food and Nutrition Supervisor Patient #1 had spoken to (referenced in the complaint intake).

In an interview on 9/8/16 at 1:00 p.m. with S3PtExpMgr, he indicated the Patient Relations Representative who had taken Patient #1's complaint on 5/30/16 had apparently never passed the information on to him or to anyone in the Dietary/Food Services Department. He confirmed there was no documented evidence to indicate further action had been taken by anyone in the Dietary/Food Services Department to investigate/resolve the patient's complaint. S3PtExpMgr said the Patient Relations Representative who had taken Patient #1's complaint information on 5/30/16 was no longer employed at the hospital.

Patient #2
Review of the Hospital's complaints/grievances revealed the following complaint made by Patient #2's husband to S6PtRelations (patient relations representative) on 5/10/16 at 8:27 a.m.: Classification: Complaint; Incident date: 5/9/16. Patient #2's husband indicated that his wife was instructed to eat only clear liquids on Sunday afternoon as she was going to have surgery on Monday. The patient had her surgery and was sent to the observation unit on 5/09/16 where she was told she could order her food. She ordered at 4:00 p.m. and around 5:00 p.m. the food was not there. She started to question the nurses as she knew shift change was going to happen soon and they advised they would look into it but 7:00 p.m. rolled around and the food was not there. They started to question new staff members after shift change who stated they would check on it but she had nothing. The patient's husband shared he went to an area diner down the street since the kitchen closed at 7:00 p.m. and got his wife some grits since she is not allowed to eat heavy food but she did not want this. He left the hospital at 9:00 p.m. and the nurse was going to try to find some food. He indicated he is not one to complain, in fact he always has good things to say about the hospital, but this situation was very frustrating for he and his wife. He wants to speak with someone in the Food/Nutrition Department about his wife's experience because he feels this was over the top.
5/10/16 8:33 follow up by S6PtRelations: I left a message for the Manager of the Call Center to discuss the patient situation.
5/10/16 8:34 a.m.: Spoke with S3PtExpMgr who shared that he will visit the patient to discuss their concerns and he will provide follow-up.

In an interview on 9/08/16 at 10:30 a.m. with S6PtRelations (patient relations representative), she confirmed her job was to receive, log, and classify patient complaints and grievances. S6PtRelations indicated it was her understating that if a complaint was resolved within the same day or within 24 hours it was considered a complaint and not a grievance. S6PtRelations also confirmed when Patient #2's complaint information was taken it was then referred to the appropriate department and further investigation was required to resolve the concerns the patient's husband had expressed.

In an interview on 9/08/16 at 11:05 a.m. with S3PtExpMgr, he indicated he had interviewed Patient #2. He said the patient had been very upset. S3PtExpMgr indicated the patient was Observation status when she failed to receive her ordered meal. S3PtExpMgr explained the issue had involved the kitchen closing at a certain time and nursing not being familiar with after-hours meal availability. He indicated he had looked into the meal order documentation and had discovered the ticket indicated the meal had left the kitchen but was apparently never delivered. He said he had no idea where the patient tray had gone.

In an interview on 9/08/16 at 11:13 a.m. with S1AsstVPPI (Assistant Vice President of Performance Improvement), she indicated, after review of the SOM Appendix A, Condition of Participation Patient Rights (42 CFR Section 482.13)-Complaints/Grievances, that if a complaint was not resolved by staff present at the time of the complaint and further investigation was required, a complaint was considered a grievance.

Based on record review and patient and staff interviews, the Hospital failed to ensure the individual patient nutritional needs were met as evidenced by failing to ensure patient meals were served at palatable temperatures for 2 of 2 (#3, #5) sampled patients on isolation precautions out of a total sample of 5 patients. Findings:

Review of the Hospital's policy titled Disposable Meal Service, Policy #C209, revealed in part the following: Disposable meal service including tray, utensils and dishes is available for residents who require them due to medical reasons or safety reasons....Isolation - no special precautions are needed for cups, dishes, glasses, trays water pitchers, or eating utensils. Both disposable or reusable dishes and utensils can be used for residents on Isolation....
Nursing: Interprets orders for isolation based on disease type and isolation protocol. Disposable meal service should be avoided as much as possible....
Dining Services: Sends up meal on disposable dishes, including disposable flatware....

Review of the Hospital's policy titled Meal Delivery & Pickup for Tray Service Only, Policy #C215 revealed in part the following: Meals will be delivered to all residents in a timely, organized and sanitary manner.
Nursing: All meals will be served within 20 minutes of delivery of food to resident areas.
Dining Services Department: Assembles meals in the kitchen and delivers them in an inclosed cart or delivers food pans to service area in closed cart....Delivers food carts to the resident areas within 15 minutes or being assembled.

There was no documented evidence of any provisions in the policy to address the specific procedure, sequence, or time frame for the delivery of disposable meal trays to ensure the food and beverages were maintained at the appropriate temperature.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a [AGE] year old admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED].

In an interview on 09/08/16 at 11:40 a.m., Patient #3 was observed to be alert and cognitive. Patient #3 confirmed she received her meals in Styrofoam containers on a disposable tray due to her isolation precautions. Patient #3 stated her food was not served at the right temperature because the food was cold when she received it. She stated she had complained to the staff and they informed her they could not re-heat the food since it had been brought into her room and she was on isolation precautions. Patient #3 also complained the milk she was served was not cold enough. Patient #3 stated she ate the salads because the other food was cold when served. Patient #3 stated she liked to eat vegetables, but they were not hot when she received her tray.

In an interview on 09/08/16 at 11:45 a.m., S4RN confirmed she was assigned to Patient #3 today and confirmed Patient #3 was cognitive. S4RN stated the patient had not voiced any complaints regarding her meal service to her, but this was the first day she had been assigned to this patient. S4RN stated meals are delivered to patients in isolation on disposable trays by the dietary staff. S4RN stated once the tray is delivered into the patient's room the nursing staff cannot re-heat the food on the tray. S4RN stated the patient would have to order another tray. S4RN confirmed the food on the disposable tray was served in styrofoam containers.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a [AGE] year old admitted on [DATE] as a transfer from another acute care hospital to be evaluated for a fecal transplant. The patient's diagnoses included [DIAGNOSES REDACTED]
Review of the physician orders revealed on 09/03/16, a Renal Diet was ordered and was the still the current diet. Further review of the physician orders revealed a Dietary Consult was ordered for the patient's severe malnutrition. Review of the physician's orders revealed the patient was placed on contact isolation upon admission and changed to Special Contact Precautions on 09/04/16 for [DIAGNOSES REDACTED]icile.

In an interview on 09/08/16 at 12:15 p.m., the patient was observed to be alert and cognitive. Also present for the interview was the patient's spouse, daughter and a female friend. When asked about the food service, the patient stated the food was not served hot. The patient's spouse, daughter, and friend all stated the food served was cold by the time the patient received the tray. The patient's daughter stated the food was served in Styrofoam containers and it was not hot. She stated the staff informed them the food could not be re-heated once the tray had entered the room. The patient's daughter stated they have to call and order another tray if they want the food hot and it takes an hour to get the new tray. The patient stated breakfast is always cold. The patient's daughter stated she goes downstairs and buys hot food in the cafeteria and brings up for her mother.

In an interview on 9/8/16 at 11:55 a.m with S5WaitStaff (Associate), she indicated her job was to deliver patient meals. She confirmed she delivered meals to patients in isolation on disposable trays with disposable plates/cutlery. S5WaitStaff explained isolation patients' meals were delivered last, after all other patient meals had been delivered.

In an interview on 09/08/16 at 1:35 p.m., S2DirFoodServ (Director of Food Services) was asked if he had received complaints related to cold food served. He stated he had not, then he stated, "It is possible there have been complaints related to cold food." When asked how the dietary department ensured food was served at the correct temperature, he stated food temperatures were checked on the plate in the dietary department and test trays are checked on the patient units. He stated at this hospital the dietary department was responsible for distributing the tray to the patient in isolation. He confirmed the Styrofoam containers did not hold heat as well as the plate warmers used for routine food service. S2DirFoodServ indicated patient meals served in Styrofoam was prepared first off the line and the trays with Styrofoam containers should be distributed first on the unit. After reviewing the above policies, he confirmed there was no current policy that included provisions directing the staff on the specific procedure, sequence, or time frame for the delivery of disposable meal trays to ensure they were delivered at the proper temperature.